Get Wi F-11096 2010

The WI F-11096 form, known as the Prior Authorization/Care Plan Attachment, is essential for coordinating health care services in Wisconsin. This guide provides clear instructions on how to fill out the form online to ensure accurate and efficient processing.

Follow the steps to complete the WI F-11096 form online.

1. Click the ‘Get Form’ button to access the form and open it in an online editor.
2. Begin by filling out Section I, which includes member information such as the member's name, telephone number, identification number, and start of care and certification period dates.
3. In Section II, enter the pertinent diagnoses and problems to be treated, including the principal diagnosis and any surgical procedures or additional diagnoses using the appropriate codes and descriptions.
4. Move on to Section III, where you will provide brief medical and social information. Include details about durable medical equipment, functional limitations, permitted activities, medications, allergies, nutritional requirements, mental status, and prognosis.
5. Proceed to Section IV to specify orders for services and treatments, including their number, frequency, and duration, as well as goals, rehabilitation potential, and discharge plans.
6. Complete Section V, which requires supplementary medical information such as the date of the last physician visit, details of any inpatient stays, current information from each discipline, and information about the member's home or social environment.
7. In Section VI, gather the required signatures from the authorized registered nurse and attending physician, ensuring all details are correctly filled out and verify the countersignature from any sharing provider.
8. Once all sections are complete, review the form for accuracy. After finalizing the information, you can save your changes, download the form, print it, or share it as necessary.

Complete your WI F-11096 form online today to ensure your healthcare needs are efficiently addressed.