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Get Hfs 10723 Wis Admin Code Form

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 F-01050A for information on completing this form. SECTION I PROVIDER INFORMATION 1. Name Specialized Medical Vehicle Company 2. Wisconsin Medicaid Provider Number Eight D.

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