Free Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements under the School-Based Services Benefit, - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1134 (10/08)

STATE OF WISCONSIN HFS 106.13, Wis. Admin. Code

WISCONSIN MEDICAID

REQUEST FOR A WAIVER TO WISCONSIN MEDICAID PRESCRIPTION REQUIREMENTS UNDER THE SCHOOL-BASED SERVICES BENEFIT
Wisconsin Medicaid requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Personally identifiable information about providers or other entities is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for services. The use of this form is mandatory. Instructions: Type or print clearly. Name -- School-Based Services (SBS) Provider Provider ID

The SBS provider named above requests a waiver under HFS 106.13, Wis. Admin. Code, for the requirement for obtaining prescriptions under the SBS benefit, following HFS 105.53(2) and 107.36(1) and (2), Wis. Admin. Code, for the following services. (Check all that apply.) Speech and language pathology, audiology, and hearing services. Physical therapy services. Occupational therapy services. Psychological services, counseling, and social work services. Under this waiver, the SBS provider is required to do all of the following: · · · Continue to meet the Department of Public Instruction and Department of Regulation and Licensing standards for prescriptions for services provided to children in the school setting under the SBS benefit. Notify the child's HMO, physician, physician specialist, physician assistant, or nurse practitioner regarding the services the child obtains under the SBS benefit at least annually. This activity must be documented in the child's record. Document communication with other Medicaid providers at least annually when a child receives similar services from other Medicaid providers. The communication must be documented in the child's record and copies of the child's Individualized Education Program must be supplied to other providers when requested. Coordinate care with managed care organizations through Memorandums of Understanding as currently required under the SBS benefit.

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Name -- SBS Provider Authorized Representative (Type or Print)

SIGNATURE -- SBS Provider Authorized Representative

Date Signed

The SBS provider requests this waiver from the Wisconsin Division of Health Care Access and Accountability for services provided on and after the following date until this requirement is eliminated through a Wisconsin Administrative Code change.

Effective Date of Waiver Request

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