Free Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report, HCF 01302 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 1302A (Rev. 07/03)

STATE OF WISCONSIN HFS 105.39, Wis. Admin. Code

WISCONSIN MEDICAID

WEEKLY DRIVER'S VEHICLE INSPECTION REPORT COMPLETION INSTRUCTIONS
Wisconsin Medicaid requires information to enable Medicaid to certify providers and to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of Medicaid payment for services. Provision of the information requested on this form is mandatory. However, the use of this version of the form is voluntary, and providers may develop their own form as long as it includes all the information on this form.
INSTRUCTIONS

1. Type or print clearly. Indicate, using "yes" or "no," if each item was inspected before the trip and was functioning during the trip. If an item did not function properly, explain the defect in the remarks section. 2. If a provider plans to use an alternate version of this form, it must be reviewed and approved by Wisconsin Medicaid prior to use. Submit the alternate version of the form to: Wisconsin Medicaid Provider Maintenance 6406 Bridge Rd Madison WI 53784-0006 Wisconsin Medicaid will notify the provider in a letter that Wisconsin Medicaid received and approved the form. An effective date for the alternate version of the form will be included in the letter. 3. This form, or an equivalent version, and a vehicle inspection must be completed every seven days for every vehicle. 4. Providers should retain a copy of the completed form in their records for 12 months. 5. In the box labeled "Vehicle Identification," enter one of the following:

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Vehicle identification number (VIN). License plate number.

6. For more information on specialized medical vehicle documentation, contact Wisconsin Medicaid Provider Services at (800) 947-9627 or (608) 221-9883.