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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