Get Wi F-11133 2011-2025

The WI F-11133 form, also known as the Personal Care Screening Tool, is essential for assessing personal care needs. This guide will provide you with clear instructions on how to complete this form online, ensuring accuracy and efficiency in the process.

Follow the steps to complete the WI F-11133 online accurately.

1. Press the ‘Get Form’ button to access the form and open it in the document editor.
2. Begin with Section I, Basic Information — Screener. Enter the name of the screening agency, the screen completion date, and the screener's telephone number. Complete the screener's name and qualifications.
3. Move to Section II, Basic Information — Member. Provide the member's name, gender, date of birth, social security number, and living situation. Make sure to specify the living situation from the provided options.
4. Input the member's address and telephone number in Section II. Also, include the county or tribe of residence and responsibility, if applicable.
5. In Section III, Insurance and Contact Information — Member, indicate the member's medical insurance. Check all applicable options and provide identification numbers where necessary.
6. Complete Section IV, Activities of Daily Living, by assessing the member's capabilities in specific daily tasks such as bathing, dressing, and grooming. Choose the responses that best reflect the member's needs.
7. Continue through Sections V and VI, focusing on medically oriented tasks and other considerations. Answer questions regarding medication assistance and behaviors that may affect care.
8. Finalize your form in Section VII by entering the billing provider's details and confirming the information's accuracy.
9. In Section VIII, the authorized screener must provide their signature and the date signed to confirm that all information is accurate.

Complete the WI F-11133 form online today to ensure proper assessment and care for personal needs.