Form F-01186 - Wisconsin Chronic Renal Disease Program Application

Form F-01186 - Wisconsin Chronic Renal Disease Program Application - 2014 Page 5

WISCONSIN CHRONIC RENAL DISEASE PROGRAM

Page 5 of 5

APPLICATION

F-01186 (02/14)

SECTION 8. CHRONIC RENAL DISEASE PATIENT MEDICAL INFORMATION

Section 8 is to be completed by a Nephrologist or Transplant surgeon at an approved facility

31. Name – Patient (Last, First, MI)

32. Patient’s primary diagnosis

(Use ICD-9-CM

code)

33. Date patient started on regular course of chronic maintenance dialysis __________________________

34. For the above patient, please indicate dates of hospitalization for initial diagnosis of chronic renal disease (if applicable) and all types

of treatments and dates of each treatment. Treatments may include disease transplant, home peritoneal dialysis, home

hemodialysis, in-center peritoneal dialysis, or in-center hemodialysis.

Hospitalization for Initial Diagnosis or

Date this type of treatment

Date this type of

Type of Treatment

began (The date entered should

treatment terminated

correspond with Item 30).

35. Name – Treating Facility

36. Wisconsin Medicaid/BadgerCare Plus Provider

identification number of facility

37. Address – Treating Facility

I certify that the above patient has been diagnosed to have end stage renal disease as defined in the Wisconsin

Administrative Code as “that stage of renal impairment which is virtually irreversible, and requires a regular course of dialysis

or kidney transplantation to maintain life.” I have read and determined that the dates in item 31 and 32 as well as other

information on this page is true and correct.

Date Signed

38. SIGNATURE – Nephrologist or Transplant Surgeon

Send completed application to:

Wisconsin Chronic Disease Program

Attn: Eligibility Unit

P.O. Box 6410

Madison, WI 53716-0410

OFFICE USE ONLY. DO NOT WRITE IN THIS SPACE.

Form F-01186 - Wisconsin Chronic Renal Disease Program Application - 2014 Page 5