Get Wi F-11134 2012-2025

Filling out the WI F-11134 form online is a crucial step for providers requesting prior authorization for personal care services in Wisconsin. This guide will walk you through each section and field to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the form with ease.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the name of the personal care services provider in the designated field. Make sure this is clear and accurate, as it identifies who is providing the services.
3. Next, input the provider number associated with the personal care services provider. This number helps to verify the provider's credentials.
4. Then, fill out the member's name with the person's full name receiving the services. Ensure that this is the correct individual, as discrepancies could delay processing.
5. In the subsequent field, enter the member ID for the individual. This unique identifier is vital for tracking and processing claims.
6. Confirm that you, as the authorized representative of the billing provider, will ensure specific tasks are completed: obtaining the physician's signed orders, conducting the assessment at the member’s residence, and developing the plan of care (POC). Make sure this commitment is clearly stated.
7. Provide your signature in the field designated for the authorized representative of the billing provider, indicating that all the information provided is accurate.
8. Finally, input the date when you are signing the form to complete the documentation. Make sure the date is accurate, as it signifies when the form was filled out.
9. After you have filled out all required fields, you can save any changes, download the form, print it for your records, or share it as necessary.

Complete your documentation online today to facilitate quick processing of your prior authorization requests.