Get Notice Of State Authorized Placement Of A Medicaid Recipient In An Out-of-state Treatment Facility

Filling out the Notice Of State Authorized Placement Of A Medicaid Recipient In An Out-of-State Treatment Facility form is essential for documenting the authorization of a Medicaid recipient's placement in a facility outside Wisconsin. This guide provides clear, step-by-step instructions for successfully completing the form online.

Follow the steps to effectively complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the Medicaid certifying agency's name and address in the designated section. This section is crucial as it identifies the agency overseeing the Medicaid recipient.
3. Fill in the Medicaid recipient's information, including their name, Medicaid number, and mailing address as listed on the Medicaid file. Ensure that this information is accurate and up-to-date.
4. Identify the party responsible for signing the Medicaid application. Provide their name, telephone number, and address. This individual is typically a family member or legal guardian.
5. Complete the medical facility section by entering the name and address of the out-of-state treatment facility. Additionally, include the name of the facility contact person and their telephone number.
6. Specify the period of authorized placement by entering the start and end dates. These dates are subject to renewal, so be mindful of them for future reference.
7. In the placement authorized by section, ensure you provide the signature of the authorized individual, along with the date authorized and their telephone number.
8. Review all entries for accuracy and completeness. Once confirmed, proceed to save any changes, download, print, or share the filled form as needed.

Begin completing your documents online today for a smooth and efficient process.