Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 1050 (11/06)

STATE OF WISCONSIN HFS 107.23, Wis. Admin. Code

WISCONSIN MEDICAID

SPECIALIZED MEDICAL VEHICLE TRANSPORTATION TRIP TICKET / MEDICAL CARE VERIFICATION
Instructions: Type or print clearly. Refer to the Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions, HCF 1050A, for information on completing this form. SECTION I -- PROVIDER INFORMATION 1. Name -- Specialized Medical Vehicle Company 2. Wisconsin Medicaid Provider Number (Eight Digits) 5. SIGNATURE -- Driver 3. Date of Trip (MM/DD/YYYY)

4. Name -- Driver (Last, First, Middle Initial)

6. Vehicle Identification or License Plate Number SECTION II -- RECIPIENT INFORMATION 9. Name -- Recipient (Last, First, Middle Initial) SECTION III -- ORIGINATING TRIP 13.

7.

Name -- Second Attendant (Last, First, Middle Initial)

8. Prescription for Second Attendant? ! Yes ! No 12. Cot or Stretcher? ! Yes ! No

10. Recipient Medicaid Identification Number

11. Wheelchair or Scooter? ! Yes ! No 14. Odometer Readings -- Unloaded Mileage ___________ Start ___________ End

Address -- Dispatch Location (Number, Street, City, State, and ZIP Code) Unloaded Mileage

15. Total Odometer Reading -- Unloaded Mileage

16.

Address -- Pick-Up Point (Name of Facility, Number, Street, City, State, and ZIP Code) Address -- Drop-Off Point (Name of Facility, Number, Street, City, State, and ZIP Code)

17.

Odometer Reading -- Trip Start Odometer Reading -- Trip End

18.

19.

20.

22.

Waiting Time 23. Waiting Time 24. More Than One Medicaid 25. Name -- Primary Rider -- Start -- End Recipient in Vehicle? ! a.m. ! a.m. ! Yes ! No ! p.m. ! p.m. SECTION IV -- RETURN TRIP (Complete this section only if information in Sections I and II apply.) 27. Address -- Dispatch Location (Number, Street, City, State, and ZIP Code) Unloaded Mileage 28. Odometer Readings -- Unloaded Mileage __________ Start __________ End 30. Address -- Pick-Up Point (Name of Facility, Number, Street, City, State, and ZIP Code) Address -- Drop-Off Point (Name of Facility, Number, Street, City, State, and ZIP Code) 31. Odometer Reading -- Trip Start 34. Odometer Reading -- Trip End

Time -- Trip Start ! a.m. ! p.m. 21. Time -- Trip End ! a.m. ! p.m. 26. Total Odometer Reading

29. Total Odometer Reading -- Unloaded Mileage

33.

36.

More Than One Medicaid Recipient in 37. Name -- Primary Rider Vehicle? ! Yes ! No SECTION V -- VERIFICATION OF MEDICAID-COVERED MEDICAL CARE (OPTIONAL) 39. Name (Printed) -- Person Verifying Medicaid Covered Service 40.

32. Time -- Trip Start ! a.m. ! p.m. 35. Time -- Trip End ! a.m. ! p.m. 38. Total Odometer Reading

Position Title -- Person Verifying Medicaid Covered Service

41.

SIGNATURE -- Person Verifying Medicaid Covered Service

42.

Date Signed -- Person Verifying Medicaid Covered Service