Form F-01184 - Wisconsin Hemophilia Home Care Program Application - 2014 Page 5
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5WISCONSIN HEMOPHILIA HOME CARE PROGRAM
Page 5 of 6
APPLICATION
F-01184 (02/14)
SECTION 8. HEMOPHILIA HOME CARE PATIENT MEDICAL INFORMATION
Section 8 is to be completed by Hematologist at approved comprehensive hemophilia treatment center.
27. Name – Patient (Last, First, MI)
28. Patient’s primary diagnosis
(Use ICD-9-CM code)
Specific laboratory factor assay result
30. Date Performed ______________________ .
29.
__________________ .
31. Name – Treating Facility
32. Wisconsin Medicaid or BadgerCare Plus Provider
identification number of facility
33. Address – Treating Facility
I hereby certify that the above-named patient is a successful member in a hemophilia home care or self-infusion training
program. The initial date of the patient’s successful participation was (34) _________________________________. I accept
the responsibility for reviewing the established maintenance program every six months and understand that I may be required
to verify that this patient continues to comply with the program.
Date Signed
35. SIGNATURE – Physician Director
Send completed application to:
Chronic Disease Program
Attn: Eligibility Unit
P.O. Box 6410
Madison, WI 53716-0410
OFFICE USE ONLY. DO NOT WRITE IN THIS SPACE.
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