Free ForwardHealth Member Request for Variance of 60-Day Supervisory Visit Requirement, F01175 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1175 (10/08)

STATE OF WISCONSIN HFS 106.13, 105.17(2)(b)(3), 107.112 (3)(c)

FORWARDHEALTH

MEMBER REQUEST FOR VARIANCE OF 60-DAY SUPERVISORY VISIT REQUIREMENT
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the service. This form is authorized under HFS 106.13, Wis. Admin. Code. Completion of this form is mandatory to obtain a variance from ForwardHealth's 60-day registered nurse (RN) supervisory visit requirement under s. HFS 105.17(2)(b)(3) and 107.112(3)(c), Wis. Admin. Code, such that visits may be made less often than every 60 days. The variance may be granted only to personal care-only agencies, not home health agencies. Name -- Member Member Identification Number

I, _____________________________________ (ForwardHealth member or guardian of member), request that ForwardHealth not require a nurse to visit my home every 60 days. I have read (or have had read to me) the attached Medical Professional Statement in Support of Request for Variance of 60-Day Supervisory Visit Requirement (F-1174) form and the updated plan of care (POC). I agree with the period between RN visits indicated in the updated POC. I understand that: I have the right to RN visits at least once every 60 days if I want them. I may contact my physician, RN, or personal care agency at any time if I want more frequent RN visits. I will contact my RN, personal care agency, or physician if I have problems with my personal care worker. I am expected to notify my ForwardHealth provider of any changes in my medical condition. The nurse and my physician have the required contact plan in place that provides for both routine and emergency contact with them. 6. My physician, RN, personal care agency, or ForwardHealth may increase the frequency of visits at any time with or without my agreement. Name -- ForwardHealth Billing Provider Telephone Number -- Provider 1. 2. 3. 4. 5.

Address -- ForwardHealth Billing Provider (Street, City, State, ZIP+4 Code)

SIGNATURE -- ForwardHealth Member or Member's Guardian

Date Signed

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