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Applicant/Member Information in the Wisconsin Well Woman Medicaid Application and Renewal form (F-10075).They will sign and date the application, 4. The WWWP provider will complete Part-B Diagnosing or Recertifying Provider in the F-10075 recording the diagnosis and indicating that treatment is required. The provider will sign and date the F-10075. The applicant and provider signature dates do not have to be the same date. 5. If doing a temporary enrollment determination: The provider will fill in the begin and end dates of the temporary enrollment for WWWMA in Part C – Temporary Enrollment / Presumptive Eligibility on the F-10075. The begin date is the date of diagnosis. The end date is the last day of the month following the month of diagnosis. See SECTION 36.2.2.2 TEMPORARY ENROLLMENT (TE) AVAILABLE ONLY TO PERSONS ENROLLING THROUGH WWWP. 6. The provider will forward a copy of the F-10075 to the WWWP coordinating agency. 7. The WWWP coordinating agency will provide the member with a copy of the signed F-10075 and F-44818 forms. 8. If doing a temporary enrollment determination: The WWWP coordinating agency will check to be sure correct temporary eligibility dates are entered on the F-10075 and explain that the client’s temporary enrollment for WWWMA will end on the last day of the following calendar month. The WWWP coordinating agency will fax a copy of the completed F-10075 to the fiscal agent at 608-221-8815 within five days of the diagnosis date. The fiscal agent will enter the temporary enrollment in ForwardHealth. 9. The WWWP coordinating agency or the member will fax, mail, or scan and email the F-10075 to EM CAPO. EM CAPO will process the application and determine eligibility for a 12-month certification period for WWWMA. EM CAPO may contact the WWWP coordinating agency for the F-44818 if EM CAPO is otherwise unable to verify the applicant’s WWWP enrollment. 36.2.2.2 Temporary Enrollment (TE) Available Only to Persons Enrolling through WWWP Temporary Enrollment (TE), also known as Presumptive Eligibility (PE), is a streamlined eligibility determination for temporary enrollment in Wisconsin Well Woman Medicaid (WWWMA). It allows eligible applicants immediate access to cancer treatment for a short period until an application for ongoing coverage is completed and processed. TE is only available to persons who are enrolling through the Wisconsin Well Woman Program (WWWP). WWWP coordinating agencies perform the eligibility determination for TE in WWWMA by completing the Wisconsin Well Woman Medicaid Application and Renewal form (F-10075), including the TE/PE section. See SECTION 36.2.2.1 WWWP PROCESS FOR ASSISTING WITH WWWMA APPLICATION. TE enrollment in WWWMA is processed by the fiscal agent. When the fiscal agent receives the F-10075 from the WWWP coordinating agency, they will enter the temporary enrollment data in ForwardHealth interChange (with a medical status code of "CB") and send the member a ForwardHealth card with the temporary enrollment dates activated on the card. If the member had a previous ForwardHealth card, it will be reactivated. Until the ForwardHealth card arrives or is reactivated, the new WWWMA member may receive services by presenting both of the following completed forms to any Medicaid provider: 1. WWWP Enrollment Form (F-44818) 2. WWWMA Application and Renewal Form (F-10075)