At Risk Pregnancy (Arp) Medical Information / Verification Form printable pdf download

STATE OF WISCONSIN

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Family and Economic Security

AT RISK PREGNANCY (ARP) MEDICAL INFORMATION / VERIFICATION FORM

Draft revised 12-14-09

Dear Physician,

The purpose of this form is to gather information for the Wisconsin Works (W-2) program At Risk Pregnancy (ARP)

placement. The W-2 ARP placement provides payment and services to eligible pregnant women who are unable to work

due to an at risk pregnancy. This placement requires:

The pregnant woman to not have custody of any dependent (minor) children in their home;

The pregnant woman to be unmarried; and

The pregnant woman to provide medical verification of:

Third trimester of pregnancy (based on the estimated delivery date);

The pregnancy is a high risk pregnancy; and

The high risk pregnancy results in the woman not being able to work.

The W-2 ARP placement requires this form (or all of the same items on the physician’s letterhead) to be completed by the

patient’s physician based on the physician’s medical examination of the patient within four months from the expected

delivery date.

Note: The information you provide on this form will not affect billing or reimbursement from Medicaid.

If you have any questions, please contact the W-2 agency at:

[Insert W-2 agency’s phone # and fax #]

Thank you!

Patient’s Full Name:

Patient’s Date of Birth:

What is the patient’s estimated delivery date?

Does this patient have a high risk pregnancy?

Yes

If yes, what is the cause of the patient’s pregnancy being a high risk pregnancy?

If yes, does the high risk pregnancy cause the patient to be unable to work (based on the physician’s best

determination)?

Yes

What is the start date (if prior to the signature date on this form) for the patient being unable to work due to

the high risk pregnancy?

Any other comments (by the patient’s physician):

Physician’s specialty area: (check all that apply)

General Medicine

Family Medicine

Obstetrics

Other, please specify:

National Provider Identifier (NPI):

Physician’s Signature:

Signature Date:

Physician’s Name (legibly printed):

Physician’s e-mail address:

Physician’s phone #:

Physician’s fax #:

Physician’s Office Address:

City:

State/Zip:

Please return the completed form to:

[Insert W-2 agency’s name, street address, city, state, zip]

At Risk Pregnancy (Arp) Medical Information / Verification Form

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