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Get Stop Work Immediately Doctor Referral Due To Pregnancy Form

STATE OF WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES Division of Family and Economic Security AT RISK PREGNANCY ARP MEDICAL INFORMATION / VERIFICATION FORM Draft revised 12-14-09 Dear Physician The purpose of this form is to gather information for the Wisconsin Works W-2 program At Risk Pregnancy ARP placement. The W-2 ARP placement provides payment and services to eligible pregnant women who are unable to work due to an at risk pregnancy. This placement requires o The pregnant woman to not have custody of any dependent minor children in their home o Third trimester of pregnancy based on the estimated delivery date o The pregnancy is a high risk pregnancy and o The high risk pregnancy results in the woman not being able to work. The W-2 ARP placement requires this form or all of the same items on the physician s letterhead to be completed by the patient s physician based on the physician s medical examination of the patient within four months from the expected delivery date. Note The information you provide on this form will not affect billing or reimbursement from Medicaid* If you have any questions please contact the W-2 agency at Insert W-2 agency s phone and fax Thank you Patient s Full Name Patient s Date of Birth / What is the patient s estimated delivery date Does this patient have a high risk pregnancy Yes No If yes what is the cause of the patient s pregnancy being a high risk pregnancy If yes does the high risk pregnancy cause the patient to be unable to work based on the physician s best determination What is the start date if prior to the signature date on this form for the patient being unable to work due to Any other comments by the patient s physician Physician s specialty area check all that apply Other please specify National Provider Identifier NPI Physician s Signature General Medicine Signature Date Physician s Office Address Physician s fax City Please return the completed form to Obstetrics Physician s Name legibly printed Physician s e-mail address Physician s phone Family Medicine State/Zip. The W-2 ARP placement provides payment and services to eligible pregnant women who are unable to work due to an at risk pregnancy. This placement requires o The pregnant woman to not have custody of any dependent minor children in their home o Third trimester of pregnancy based on the estimated delivery date o The pregnancy is a high risk pregnancy and o The high risk pregnancy results in the woman not being able to work. This placement requires o The pregnant woman to not have custody of any dependent minor children in their home o Third trimester of pregnancy based on the estimated delivery date o The pregnancy is a high risk pregnancy and o The high risk pregnancy results in the woman not being able to work. The W-2 ARP placement requires this form or all of the same items on the physician s letterhead to be completed by the patient s physician based on the physician s medical examination of the patient within four months from the expected delivery date.

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