Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 1198 (Rev. 12/04)

STATE OF WISCONSIN

WISCONSIN MEDICAID

OPTIONAL SCHOOL-BASED SERVICES ACTIVITY LOG NURSING / THERAPY MEDICAL SERVICES
Name -- Student (Last, First, MI) Name -- School Method Used (Circle One) Time Date of Service (MM/DD/YY) General Service Category Unit of Service (Time or Units) Group or Individual Describe Specific Services Performed Student's Response/ Progress Task Initials or Signature* (Of Person Who Performed Service)

*Initials Key

Signatures -- Corresponding Staff

Date Signed (MM/DD/YY)

Therapy services only: A. Does the recipient have insurance? Yes No (If yes, go to B. If no, stop.) B. Is there an insurance exclusionary clause for all school-based services? Yes No (If yes, insurance liability does not apply. If no or do not know, go to C.) C. Check the option selected: Option 1: School assuming insurance liability. (Subtract the first occurring unit of occupational therapy [OT] [group or individual] and/or physical therapy [PT] [group or individual] during the calendar month from the monthly claim for services. Bill the remaining services to Wisconsin Medicaid. Do not indicate an "other insurance" disclaimer code in Element 9 of the CMS 1500 claim form.) Option 2: School seeking insurance payment for OT (group or individual) and/or PT (group or individual). Schools must have parental permission for this option. Option 3: School not seeking Medicaid payment for OT (group or individual) and/or PT (group or individual).