048-2 Wyo. Code R. §§ 2-4 - Application Process

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.

Notes

048-2 Wyo. Code R. §§ 2-4