Get Hfs 10723 Wis Admin Code Form

Completing the Hfs 10723 Wis Admin Code Form accurately is essential for ensuring proper transportation services under Wisconsin Medicaid. This guide provides step-by-step instructions to help users fill out and submit the form online with confidence.

Follow the steps to successfully complete your Hfs 10723 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, provide the specialized medical vehicle company name and Medicaid provider number. Enter the driver's full name, their signature, vehicle identification number, and the date of the trip.
3. Provide the name of the second attendant if necessary, and indicate whether there is a prescription for the second attendant.
4. Move to Section II and fill in the member's name and Medicaid identification number. Also, specify if a wheelchair or scooter is used and if a cot or stretcher is required.
5. In Section III, input the dispatch location address for the trip and note the odometer readings for both start and end points. Complete the pick-up and drop-off addresses along with the corresponding odometer readings.
6. Record the waiting times and if there is more than one Medicaid member in the vehicle for the trip.
7. If applicable, complete Section IV for the return trip with similar details regarding the dispatch, pick-up, and drop-off points along with odometer readings.
8. Lastly, in Section V, if verifying medical care, enter the verifiers' full name, position title, signature, and the date signed.
9. After filling out all the necessary sections, review the form for accuracy, then save changes. You may download, print, or share the completed form as needed.

Now that you have the guidance, complete your Hfs 10723 Wis Admin Code Form online today.