Free Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart, F01301 - Wisconsin


File Size: 99.3 kB
Pages: 1
Date: January 26, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BBM
Word Count: 224 Words, 1,510 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F0/F01301.pdf

Download Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart, F01301 ( 99.3 kB)


Preview Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart, F01301
DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1301 (10/08)

STATE OF WISCONSIN HFS 105.39, Wis. Admin. Code

WISCONSIN MEDICAID

SPECIALIZED MEDICAL VEHICLE DRIVER INFORMATION CHART
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. Return completed forms to ForwardHealth, Provider Maintenance, 6406 Bridge Road, Madison, WI 53784-0006.
Name -- Specialized Medical Vehicle (SMV) Company Address -- SMV Company (Street, City, State, and ZIP+4 Code) Provider ID

Driver's License Name -- Driver (Print) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. By signing this form, I affirm that I have reviewed the information on this form and found it to be correct. SIGNATURE -- Person Completing Form Name -- Person Completing Form (Print) Position Title Driver's License Number License Expiration Date (MM/DD/CCYY) Type Regular / Commercial Restrictions (List All) First Aid Course Date

First Aid Course Name and Date CPR Date Ramp / Lift / Restraint Date Seizure Date

Date Signed

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