Certification Of Emergency For Non-U.s. Citizens

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01162 (02/09)
FORWARDHEALTH
CERTIFICATION OF EMERGENCY FOR NON-U.S. CITIZENS
Instructions: Type or print clearly. After the provider completes the form, the patient should take this form to the local county or tribal
agency in his or her county of residence where the enrollment decision is made. Providers are encouraged to keep a copy for their
records. Reimbursement for the emergency service is conditional on meeting all program rules, including the definition of an emergency
medical condition as described in the instructions. Before completing this form, read the Certification of Emergency for Non-U.S.
Citizens Completion Instructions, F-01162A.
SECTION I — PATIENT INFORMATION
1.
Name — Patient
2.
Address — Patient
3.
Date of Birth — Patient
4.
Social Security Number — Patient
5.
Emergency Start Date
6.
Emergency End Date
7.
Name — Contact Person
8.
Telephone Number — Contact Person
SECTION II — PROVIDER INFORMATION AND AUTHORIZATION
I verify that the above-named patient was treated for an emergency medical condition as defined under 42 CFR s. 440.255(c)(1).
9.
Name — Provider
10. SIGNATURE — Provider
11. Date Signed
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