Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1162 (02/09)

STATE OF WISCONSIN

FORWARDHEALTH

CERTIFICATION OF EMERGENCY FOR NON-U.S. CITIZENS
Instructions: Type or print clearly. After the provider completes the form, the patient should take this form to the local county or tribal agency in his or her county of residence where the enrollment decision is made. Providers are encouraged to keep a copy for their records. Reimbursement for the emergency service is conditional on meeting all program rules, including the definition of an emergency medical condition as described in the instructions. Before completing this form, read the Certification of Emergency for Non-U.S. Citizens Completion Instructions, F-1162A. SECTION I -- PATIENT INFORMATION 1. Name -- Patient 2. Address -- Patient

3.

Date of Birth -- Patient

4.

Social Security Number -- Patient

5.

Emergency Start Date

6.

Emergency End Date

7.

Name -- Contact Person

8.

Telephone Number -- Contact Person

SECTION II -- PROVIDER INFORMATION AND AUTHORIZATION I verify that the above-named patient was treated for an emergency medical condition as defined under 42 CFR s. 440.255(c)(1). 9. Name -- Provider

10. SIGNATURE -- Provider

11. Date Signed

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