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Get Wi F-01153 2022-2024

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1153 02/09 STATE OF WISCONSIN FORWARDHEALTH BREAST PUMP ORDER ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full correct and truthful information for the submission of correct and complete claims for reimbursement. This information should include but is not limited to information concerning enrollment status accurate name address and member identification number DHS 104. 02 4 Wis. Admin* Code. Under s. 49. 45 4 Wis. Stats. personally identifiable information about applicants and members is confidential and is used for purposes directly related to ForwardHealth 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 payment for the services. INSTRUCTIONS Type or print clearly. This form is to be completed by the physician given to the provider of the breast pump and kept in the member s medical record as required under DHS 106. 02 9 Wis. Admin* Code. The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form* 1. Date of Order 2. Name Member Mother 3. Address Member 4. Date of Birth Infant 5. Member ID 6. Clinical Guidelines All of the following must apply as a condition for coverage. By checking the boxes the physician verifies that all conditions are met. Physician ordered or recommended breast milk for infant. Potential exists for adequate milk production* Member plans to breast-feed long term* Member is capable of being trained to use the breast pump* Current or expected physical separation of mother and infant e*g* illness hospitalization work would make breast-feeding difficult or there is difficulty with latch on due to physical emotional or developmental problems of the mother or infant. 7. Type of Pump The physician orders or recommends the following breast pump for use by the member Breast pump manual any type. Breast pump electric AC and / or DC any type. Breast pump heavy duty hospital grade piston operated pulsatile vacuum suction / release cycles vacuum regulator supplies transformer electric AC and / or DC. Members of ForwardHealth are required to give providers full correct and truthful information for the submission of correct and complete claims for reimbursement. This information should include but is not limited to information concerning enrollment status accurate name address and member identification number DHS 104. This information should include but is not limited to information concerning enrollment status accurate name address and member identification number DHS 104. 02 4 Wis. Admin* Code. Under s. 49. 45 4 Wis. Stats. personally identifiable information about applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant or processing provider claims for reimbursement.

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Keywords relevant to WI F-01153

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  • e0602
  • wis
  • reimbursement
  • hospitalization
  • verifies
  • ELIGIBILITY
  • identifiable
  • Providers
  • developmental
  • Admin
  • enrollment
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  • Applicant
  • medicaid
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