Get Wi F-11096 2015-2025

The WI F-11096, also known as the prior authorization/care plan attachment, is a critical form used for essential medical services in Wisconsin. This guide will help you navigate the online completion of this form with clear instructions for each section.

Follow the steps to successfully fill out the WI F-11096.

1. Click the ‘Get Form’ button to access the WI F-11096. This action will open the form in an online editor for you to complete.
2. Section I — Member information: Clearly input the member's full name, telephone number, member identification number, start of care date, and certification period (both from and to dates).
3. Section II — Pertinent diagnoses and problems to be treated: Enter the principal diagnosis along with its ICD code, description, and date of diagnosis. Include any surgical procedures and other relevant diagnoses following the same format.
4. Section III — Brief medical and social information: Fill in details about durable medical equipment, any functional limitations by selecting the appropriate options, and specify the activities permitted.
5. Continue in Section III by documenting medication details (dose, frequency, route), allergies, nutritional requirements, and mental status by selecting the most accurate options.
6. Further in Section IV — Orders, outline orders for services and treatments, including number, frequency, and duration. Follow this with goals, rehabilitation potential, and discharge plans.
7. In Section V — Supplementary medical information, provide the date the physician last saw the member, dates of any recent inpatient stays, and information regarding the facility of the last stay if applicable.
8. Conclude Section V by detailing any medical and nonmedical reasons the member regularly leaves home and names of other providers involved in the case.
9. Section VI — Signatures: Ensure all necessary parties sign and date the form appropriately, including the nurse, physician, and any countersigning providers.
10. After completing all sections, save your changes, and you can then download, print, or share the completed form as needed.

Complete the WI F-11096 online today for prompt processing of your medical authorization needs.