Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability F-10111 (07/08)

STATE OF WISCONSIN
WI Stats. ss. 49.665, 49.468, 49.472, 49.473

GOOD FAITH MEDICAID / BADGERCARE PLUS CERTIFICATION
Claim Type Internal Control Number Check Digit From Dates of Service on Claim To

SECTION I ­ AGENCY DENIAL
Agency Denial

Yes No If `NO', complete and attach a F-10128 to update the member's file.

Reason for Denial Member did not have a valid "Forward" ID card after ____________(date). Member not eligible. Record not found.

Partial Denial From To

SECTION II ­ TYPE OF CERTIFICATION ACTION
Initial Certification (Cert1) Agency Number W2 Agency Code Amended Certification (Cert 3) Case Head Name (Last, First, MI)

Case Head Current ID Medical Status Code Period of Certification Thru

In Care of Street Address City, State, Zip Code

From

Previous ID Number Control Name YOB Eligible Member's Name (Last, First, MI) Birthdate (mm/dd/ccyy) Gender Male Female

A 71 (good faith) med status has been applied to this member's file for the dates of service. In order to change the med status, or any other information, a Cert. 3 - 3070 is needed. Other Remarks:

SECTION III - SIGNATURE
SIGNATURE ­ Authorized Agency Representative

Worker ID Number

Date Signed

Questions may be directed to Good Faith staff by calling: (608) 221-4746, ext. 3104.

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