Medicine and Surgery Section - Wisconsin.gov

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DEPARTMENT OF HEALTH AND FAMILY SERVICES HCF 1160 (Rev. 09/05) WISCONSIN MEDICAID ACKNOWLEDGMENT OF RECEIPT OF HYSTERECTOMY INFORMATION Page 2 of 2 Name — Recipient Recipient Medicaid Identification Number Address — Recipient Name — Physician Wisconsin Medicaid Provider Number It has been explained (Name — Recipient) performed on her (me) will render her (me) permanently incapable of reproducing. SIGNATURES — Recipient, Representative, and Interpreter Recipient Date Signed Representative Date Signed Interpreter Date Signed (me) that the hysterectomy to be
Appendix 14 Breast Pump Order (for photocopying) (A copy of the Breast Pump Order form is located on the following page.) Physician Services Handbook — Medicine and Surgery December 2005 109 Appendix
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Physician Services Medicine and Sur
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T Table of Contents Preface .......
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Telemedicine ......................
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Health Professional Shortage Areas
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Legal Framework The following laws
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General Information Treatment (EPSD
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General Information Category III Co
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General Information collecting the
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General Information • The current
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Evaluation and Management reimburse
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Evaluation and Management in an out
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Evaluation and Management 22 Wiscon
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Medicine Services System [HCPCS] co
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Medicine Services In cases where mo
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Medicine Services documentation in
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Medicine Services Providers of ment
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Medicine Services Substance Abuse S
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Surgery Services Appendix 10 of thi
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Surgery Services Cataract Surgery W
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Surgery Services and the insertion
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Surgery Services Note: A telephone
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Surgery Services • Sterilization.
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Surgery Services live with her sinc
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Surgery Services by a multi-discipl
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Prescription Requirements Prescribe
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Prescription Requirements Approval
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Prescription Requirements prescribe
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Prescription Requirements 54 Wiscon
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Claims Submission adjustment reques
Page 60 and 61: Claims Submission 58 Wisconsin Medi
Page 62 and 63: Reimbursement • Confirming or rev
Page 64 and 65: Reimbursement about whether a speci
Page 66 and 67: Reimbursement 64 Wisconsin Medicaid
Page 68 and 69: Appendix 66 Wisconsin Medicaid and
Page 70 and 71: Appendix Surgery Services Appendix
Page 72 and 73: Appendix Medicine Services (Continu
Page 74 and 75: Appendix Other Services Appendix 1
Page 80 and 81: Appendix Appendix 4 (Continued) If
Page 82 and 83: Appendix Appendix 4 (Continued) Ele
Page 84 and 85: Appendix Appendix 4 (Continued) Ele
Page 96 and 97: Appendix (This page was intentional
Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
Page 114 and 115: Appendix Appendix 15 (Continued) Pe
Page 116 and 117: Appendix Category Musculoskeletal S
Page 118 and 119: Appendix Category Musculoskeletal S
Page 120 and 121: Appendix Category Female Genital Sy
Page 122 and 123: Appendix SECTION II — RECIPIENT I
Page 132 and 133: Appendix PRIOR AUTHORIZATION / PHYS
Page 136 and 137: PRIOR AUTHORIZATION / PHYSICIAN ATT
Page 140 and 141: PRIOR AUTHORIZATION / “J” CODE
Page 144 and 145: PRIOR AUTHORIZATION / “J” CODE
Page 148 and 149: PRIOR AUTHORIZATION / PHYSICIAN OTO
Page 152 and 153: Appendix Health Professional Shorta
Page 154 and 155: Appendix HPSA Name County ZIP Codes
Page 158 and 159: Appendix Appendix 26 (Continued) ma
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Appendix The following table lists
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Appendix 160 Wisconsin Medicaid and
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Appendix (This page was intentional
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DEPARTMENT OF HEALTH AND FAMILY SER
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Appendix (This page was intentional
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DECLARATION OF SUPERVISION FOR NONB
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Appendix HCPCS Code* Drug Name Diag
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Index Organ Transplants, 44 Provide
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