Free Wisconsin Medicaid Out-of-State Provider Data Sheet, F11001 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11001 (10/08)

STATE OF WISCONSIN HFS 105.03(1) and 105.48, Wis. Admin. Code

WISCONSIN MEDICAID

OUT-OF-STATE PROVIDER DATA SHEET
Instructions: Type or print clearly. Before completing this form, read Out-of-State Provider Data Sheet Completion Instructions, F-11001A. This is required in order to submit claims or prior authorizations for services performed outside Wisconsin. Submit the completed form with attachments to ForwardHealth, Out-of-State Claims, 6406 Bridge Road, Madison, WI 53784-0007. Reason for Sending Out-of-State Provider Data Sheet -- Check One Prior Authorization 1. Name -- Provider Claim for Emergency Services Update to Provider Data 2. Provider ID

SECTION I -- PRACTICE LOCATION INFORMATION

3. Address Line 1

4. Address Line 2

5. City

6. State

7. ZIP+4 Code

8. Gender Male Female

9. Name -- Contact Person

10 Telephone Number -- Contact Person

SECTION II -- PROVIDER FINANCIAL INFORMATION Taxpayer Information 11. Taxpayer Identification Number (TIN)

12. Name -- Taxpayer

13. TIN Type EIN 16. Address Line 1 SSN

14. TIN Effective Date

15. TIN End Date

Checks and Remittance Advice Information 17. Address Line 2

18. City

19. State

20. ZIP+4 Code

21. Name -- Financial Contact Person

22. Telephone Number -- Contact Person

IRS Form 1099 Mailing Address 23. Address Line 1

24. Address Line 2

25. City

26. State

27. ZIP+4 Code

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OUT-OF-STATE PROVIDER DATA SHEET F-11001 (10/08)

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SECTION III -- MAILING INFORMATION 28. Name -- Mail To 29. Name -- Attention Line

30. Address Line 1

31. Address Line 2

32. City

33. State

34. ZIP+4 Code

SECTION IV -- PRIOR AUTHORIZATION INFORMATION 35. Name -- Provider 36. Name -- Attention Line

37. Address Line 1

38. Address Line 2

39. City

40. State

41. ZIP+4 Code

42. Fax Number

43. Telephone Number -- Contact Person

SECTION V -- GENERAL INFORMATION 44. Refer to page 3 of this form and choose the applicant's appropriate provider type and specialty. 45. Medicare Enrollment Information Check all applicable types of enrollment. Part A Effective Date ___________________ Part B Effective Date ___________________ DMERC Effective Date ___________________ Note: Wisconsin Medicaid will use the NPI indicated in Section I of this form for processing automatic Medicare crossover claims. 46. Clinical Laboratory Improvement Amendment (CLIA) Number

47a. Drug Enforcement Agency (DEA) Number(s)

47b. DEA Number(s)

47c. DEA Number(s)

47d. DEA Number(s)

48. Individual or Organization License and State of License

SECTION VI -- 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. 49. SIGNATURE -- Provider or Authorized Agent (Required) 50. Date Signed (Required)

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OUT-OF-STATE PROVIDER DATA SHEET F-11001 (10/08)

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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 44. 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 27. Dentist.......................................................................................................................................................................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.

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