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Wisconsin Department of Health Services

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SeniorCare Home

What Is It?

Should I Apply?

Am I Eligible?
(ACCESS)

Check My Benefits
(ACCESS)

Where Do I Apply?

SeniorCare Application Form and Instructions

Publications

Income Limits/FPL

Waiver Information

HIPAA Privacy Notice

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SeniorCare Notice of Privacy Practices

Privacy Notice and Forms

  • SeniorCare Notice of Privacy Practices (English, Hmong, Laotian [PDF, 312KB], Russian, Spanish)
  • Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure — F-3161 (PDF 109 KB)
  • Wisconsin SeniorCare HIPAA Privacy Access Request — F-13162 (PDF 100 KB)
  • Wisconsin SeniorCare HIPAA Privacy Accounting Request — F-13163 (PDF 92 KB)
  • Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request — F-13164 (PDF 96 KB)
  • Wisconsin SeniorCare HIPAA Privacy Amendment Request — F-13165 (PDF 88 KB)
  • Wisconsin SeniorCare HIPAA Privacy Complaint — F-13166 (PDF 92 KB)
  • Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization — F-13167 (PDF 96 KB)
  • Wisconsin SeniorCare HIPAA Privacy Restriction Request — F-13168 (PDF 88 KB)
  • SeniorCare Authorization of Representative — F-10080 (PDF 72 KB)

 

Spanish - 

Si necesita ayuda para traducir o entender este texto, por favor llame al telιfono 1-800-657-2038 (V/TTY) 
Russian -   Если вам не всё понятно в этом документе, позвоните по телефону
1-800-657-2038 (V/TTY)
Hmong - Yog xav tau kev pab txhais cov ntaub ntawv no kom koj totaub, hu rau
1-800-657-2038 (V/TTY)
Laotian - How to get access to information in Laotian
1-800-657-2038 (V/TTY)

Date Last Revised: November 22, 2011