Free Wisconsin Medicaid Certification of Public Expenditures, HCF 1103 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 1003 (Rev. 12/04)

STATE OF WISCONSIN Chapter 49.45(39)(b), Wis. Stats.

WISCONSIN MEDICAID

CERTIFICATION OF PUBLIC EXPENDITURES
Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. The Certification of Public Expenditures form provides Wisconsin Medicaid with certification of expenditures by school districts and Cooperative Educational Service Agencies (CESAs) for Medicaid-covered services. This form will be retained as part of the fiscal documentation for Wisconsin Medicaid. The Certification of Public Expenditures is used by Wisconsin Medicaid and is a mandatory form. Failure to submit this form by the due date certifying an adequate amount of expenditures may result in the recoupment of Medicaid payments. Providers may submit the signed Certification of Public Expenditures by fax to (608) 266-1096 to the attention of the school-based services (SBS) Policy Analyst or by mail to the following address: SBS Policy Analyst/Certification of Public Expenditures Division of Health Care Financing PO Box 309 Madison WI 53701-0309 For the purposes of this form, "Medicaid-covered school-based services" include the services identified in HFS 107.36, Wis. Admin. Code, and outlined in the School-Based Services Handbook. SECTION I -- PROVIDER INFORMATION Report Period Wisconsin Medicaid Provider Identification Number

Name and Address -- Provider

Wisconsin Medicaid records indicate that during the report period, Wisconsin Medicaid reimbursed this provider a total of $___________________ in federal Medicaid funds, for the Medicaid-covered school-based services. SECTION II -- CERTIFICATION This is to certify that: · · I am authorized to review, sign, and submit this form on behalf of this school district. This provider expended at least $___________________ in public funds for Medicaid-covered school-based services, provided to Wisconsin Medicaid recipients during the report period. Further, These public funds are not obligated to match other federal funds for any federal program. These public funds are not federal funds, unless they are federal funds that are authorized by federal law to be used to match other federal funds. · · Records documenting these public expenditures are on file and are available for review. I have reviewed the foregoing and certify that the information reported is true and correct to the best of my knowledge and belief.

SECTION III -- SIGNATURE SIGNATURE -- Authorized Representative Date Signed

Name -- Authorized Representative (print)

Telephone Number -- Authorized Representative

Title -- Authorized Representative

E-mail Address -- Authorized Representative

Reset Form