Current through September 21, 2024
In making application, a person must submit or have submitted
on their behalf the following documents:
(a) A properly completed and signed original
Application for Program Benefits, including the signed authorization to
Furnish/Release Information;
(b)
Copies of acceptable evidence of residency, Copies of any two of the following
documents will be considered acceptable to determine residency;
(i) A current, valid Wyoming driver's license
or identification card with a current Wyoming address;
(ii) A copy of a current, valid Wyoming
voter's registration card;
(iii)
Mortgage or rent payment receipts in the name of the applicant or her spouse
from the two (2) months immediately preceding the date of application revealing
a verifiable Wyoming address;
(iv)
Utility payment receipts in the name of the applicant or his spouse for the two
(2) months immediately preceding the date of application revealing payment of
utilities for a Wyoming address;
(v) Wyoming property tax receipts for the
most recently completed tax year;
(vi) Wyoming employment/unemployment
records;
(vii) Postal verification
of a Wyoming address; or
(viii)
Current Wyoming resident hunting or fishing license.
(c) A copy of the properly completed, signed
and dated End Stage Renal Disease Medical Evidence Report (CMS Form 2728);
(i) This requirement is waived for kidney
transplant recipient applicants. A letter from the applicant's nephrologist
attesting to the transplanted kidney will he considered an acceptable
substitute in this circumstance.
(d) A copy of the applicant's Social Security
card;
(e) Copies of all current
insurance cards;
(f) Copies of
outstanding or current bills relating to the applicant's ESRD;
(g) Verification of income for all members of
the household to determine financial eligibility;
(i) A copy of a financial statement form
acceptable to the Program (e.g., filed income tax returns, Social Security
statements, bank statements, copies of W-2 forms, retirement statements);
or
(ii) If the applicant's current
gross income has become significantly reduced, a more detailed financial
statement listing income information may be required.
