Free Wisconsin Medicaid In-State Emergency Provider Data Sheet, F11002 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11002 (10/08)

STATE OF WISCONSIN HFS 105.03(1), Wis. Admin. Code

WISCONSIN MEDICAID

IN-STATE EMERGENCY PROVIDER DATA SHEET
Instructions: Type or print clearly. Before completing this form, read In-State Emergency Provider Data Sheet Completion Instructions, F-11002A. This is required in order to submit claims for emergency services. Submit the completed form with any applicable attachments to ForwardHealth, In-State Emergency Claims, 6406 Bridge Road, Madison, WI 53784-0011. SECTION I -- PRACTICE LOCATION INFORMATION 1. Name -- Provider 2. Provider ID

3. Address Line 1

4. Address Line 2

5. City

6. State

7. ZIP+4 Code

8. County

9. Gender Male Female

10. Name -- Contact Person

11. Telephone Number -- Contact Person

SECTION II -- PROVIDER FINANCIAL INFORMATION Taxpayer Information 12. Taxpayer Identification Number (TIN) 13. Name -- Taxpayer

14. TIN Type EIN

15. TIN Effective Date SSN

16. TIN End Date

Checks and Remittance Advice Information 17. Address Line 1 18. Address Line 2

19. City

20. State

21. ZIP+4 Code

22. Name -- Financial Contact Person

23. Telephone Number -- Contact Person

IRS Form 1099 Mailing Address 24. Address Line 1

25. Address Line 2

26. City

27. State

28. ZIP+4 Code

Continued

IN-STATE EMERGENCY PROVIDER DATA SHEET F-11002 (10/08)

Page 2 of 3

SECTION III -- MAILING INFORMATION 29. Name -- Mail To

30. Name -- Attention Line

31. Address Line 1

32. Address Line 2

33. City

34. State

35. ZIP+4 Code

SECTION IV -- GENERAL INFORMATION 36. Refer to page 3 of this form and choose the applicant's appropriate provider type and specialty. 37. Medicare Enrollment Information Check all applicable types of enrollment. Part A Part B DMERC Effective Date Effective Date Effective Date

Note: Wisconsin Medicaid will use the NPI indicated in Section II of this form for processing automatic Medicare crossover claims. 38. Clinical Laboratory Improvement Amendment (CLIA) Number

39a. Drug Enforcement Agency (DEA) Number(s)

39b. DEA Number(s)

39c. DEA Number(s)

39d. DEA Number(s)

40. Individual or Organization License and State of License

SECTION V -- AUTHORIZED SIGNATURE INFORMATION I affirm that services provided are medically indicated and necessary to the patient's health. The services are within the scope of my (our) licensure. I understand that any false claims, settlements, documents, or concealment of material fact may be prosecuted under applicable federal and state law. I further affirm that to the best of my knowledge the information presented here is accurate and complete. 41. SIGNATURE -- Provider or Authorized Agent (Required) 42. Date Signed (Required)

Continued

IN-STATE EMERGENCY PROVIDER DATA SHEET F-11002 (10/08)

Page 3 of 3

Key Attach the required copies, as indicated, to the data sheet: A = Copy of license covering date of service. B = Copy of Medicare enrollment approval. C = Copy of approvals/certifications from appropriate associations and organizations (e.g., American Speech-Language Hearing Association). D = Copy of approval by the Joint Commission (Formerly the Joint Commission on Accreditation of Healthcare Organizations). Circle the number that indicates the applicant's provider type and specialty as instructed in Element 36. Complete "Other" if the applicable provider type and specialty are not listed. Types / Specialties Materials to Be Submitted with Data Sheet

26. Ambulance, Land or Air ............................................................................................................................................A 02. Ambulatory Surgery Center.......................................................................................................................................B 32. Anesthesiologist Assistant / Certified Registered Nurse Anesthetist (Not an M.D.) ..................................................A 20. Audiologist ................................................................................................................................................................C 15. Chiropractor ..............................................................................................................................................................A 30. End-Stage Renal Disease Service............................................................................................................................B 22. Hearing Instrument Specialist ...................................................................................................................................A 05. Home Health Agency ................................................................................................................................................B 05 / 053. Home Health Agency (With Personal Care)..............................................................................................................B 06. Hospice .....................................................................................................................................................................B 01. Hospital .....................................................................................................................................................................A & B or D 53. Individual Medical Supply, List specialty. ...........................................................C (e.g., Individual Orthotist, Individual Prosthetist) 58. Institutes for Mental Disease.....................................................................................................................................A 28 / 280. Laboratory / Independent Lab ...................................................................................................................................B 11 / 112. Licensed Psychologist (With Ph.D.) ..........................................................................................................................A 25. Medical Equipment Vendor .......................................................................................................................................C 09. Nurse Practitioner .....................................................................................................................................................A & C 16. Nurse Services, List specialty. .......................................................................A (e.g., Registered Nurse, Licensed Practical Nurse, Respiratory Care, Nurse Midwife, Independent Nurse) 03. Nursing Home....................................................................................................................................................A 78. Occupational Therapist .............................................................................................................................................A 19. Optician.....................................................................................................................................................................C 18. Optometrist ...............................................................................................................................................................A 05/052. Personal Care Agency ..............................................................................................................................................A 24. Pharmacy..................................................................................................................................................................A 77. Physical Therapist.....................................................................................................................................................A 31. Physician (M.D.), List specialty. .......................................................................A (e.g., General Practice, Psychiatry. If specialty is psychiatry, send proof of completed residency.) 14. Podiatrist ...................................................................................................................................................................A 29. Portable X-ray ...........................................................................................................................................................B 04. Rehabilitation Agency ...............................................................................................................................................B 74. Speech and Hearing Clinic........................................................................................................................................C 79. Speech-Language Pathologist (Bachelor's or Master's Degree)...............................................................................C Other. Explain the applicant's specialty in the space provided and submit the applicable required materials (A-D) or requirements of the state in which certification is maintained.

Reset Form