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Get WI F-11278 2012-2024

Lth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Personally identifiable information about providers or other entities is used for purposes directly related to program administration such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for services. The use of this form is mandatory. I.

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