Free Wisconsin Medicaid Specialized Medical Vehicle Information Chart, F01300 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1300 (10/08)

STATE OF WISCONSIN HFS 105.39, Wis. Admin. Code

WISCONSIN MEDICAID

SPECIALIZED MEDICAL VEHICLE 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

Vehicle Identification

License Plate Number

Plate Expiration Date (MM/DD/YY)

Vehicle Year (CCYY)

Vehicle Make

Vehicle Model

Ramp (Yes / No)

Lift (Yes / No)

Cot / Stretcher (Yes / No)

1. 2. 3. 4. 5. 6. I affirm that the vehicles listed on this form meet HFS 107.23 and 105.39, Wis. Admin. Code, requirements for a human services vehicle serving the disabled and elderly. SIGNATURE -- Person Completing Form Name -- Person Completing Form (print) Job Title Date Signed

Reset Form