Free ForwardHealth Newborn Report, F-1165, F01165 - Wisconsin

File Size: 35.4 kB
Pages: 1
Date: May 28, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Word Count: 362 Words, 2,403 Characters
Page Size: Letter (8 1/2" x 11")

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1165 (05/09)



ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members 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 (DHS 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. The use of this form is mandatory when notifying ForwardHealth of a newborn born to a Medicaid or BadgerCare Plus member. INSTRUCTIONS Type or print clearly. All requested information must be provided. In multiple birth situations, a separate Newborn Report must be filled out for each birth. For more information on newborn reporting, contact Provider Services at (800) 947-9627. Submit completed forms via fax at (608) 224-6318 or by mail to the following address: ForwardHealth PO Box 6470 Madison WI 53716 SECTION I -- HOSPITAL (OR OTHER PROVIDER) INFORMATION Name -- Hospital (or Other Provider)

Hospital's National Provider Identifier

Taxonomy Code

Practice Location ZIP+4 Code

Name -- Contact Person

Telephone Number -- Contact Person

SECTION II -- NEWBORN INFORMATION Name -- Newborn (First, Middle Initial, Last) Gender

Date of Birth (MM/DD/CCYY)

Date of Death, if applicable (MM/DD/CCYY)

Multiple Births (If yes, complete a form for each birth.) Yes No SECTION III -- MOTHER INFORMATION Name -- Mother

Newborn Weight is Less Than 1200 Grams Yes No Member ID -- Mother

Address (Street, City, State, and ZIP Code)

Member ID -- Case Head

SECTION IV -- AUTHORIZATION This information is accurate to the best of my knowledge. SIGNATURE -- Hospital (or Other Provider) Representative Date Signed

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