Free Wisconsin Medicaid Declaration of Supervision for Nonbilling Providers, F01182 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1182 (10/08)

STATE OF WISCONSIN HFS 105.02(1), Wis. Admin. Code

WISCONSIN MEDICAID

DECLARATION OF SUPERVISION FOR NONBILLING PROVIDERS
Wisconsin Medicaid requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Personally identifiable information about providers and other entities is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for those services. The use of this form is mandatory. INSTRUCTIONS Nonbilling providers receive nonbilling provider numbers. The numbers cannot be used independently to bill Wisconsin Medicaid. The following nonbilling providers are required to complete the Provider Change of Address or Status form, F-1181, for changes in physical address and all supervisor changes: · · · · Occupational Therapy Assistants. Physical Therapist Assistants. Physician Assistants. Speech Therapists, Bachelor of Arts (BA) level.

The nonbilling provider(s) who has changed his or her work address or supervisor should complete Section I. The nonbilling provider's supervisor should complete Section II. Return the completed form to Wisconsin Medicaid, Provider Maintenance, 6406 Bridge Road, Madison WI 53784-0006. For more information, contact Provider Services at (800) 947-9627. SECTION I -- NONBILLING PROVIDER INFORMATION Name and Credentials -- Nonbilling Provider Provider ID

Address -- Nonbilling Provider

Telephone Number -- Nonbilling Provider

SIGNATURE -- Nonbilling Provider

Date Signed

SECTION II -- SUPERVISOR INFORMATION Name -- Supervisor

Street Address Line 1

Street Address Line 2

City

State

ZIP+4 Code

Telephone Number -- Supervisor

Supervisor's Effective Starting Date



I affirm that
(Name of Supervisor Above)

is supervising my work as a nonbiller with Wisconsin . If
(Date Listed Above) (Name of Supervisor Above)

Medicaid effective

discontinues

Supervision with me, I understand that I must update this information with Wisconsin Medicaid.

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