Specialized Medical Vehicle Transportation Trip Ticket
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 107.23, Wis. Admin. Code
F-01050 (07/08)
WISCONSIN MEDICAID
SPECIALIZED MEDICAL VEHICLE
TRANSPORTATION TRIP TICKET / MEDICAL CARE VERIFICATION
Instructions: Type or print clearly. Refer to the Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion
Instructions, F-01050A, for information on completing this form.
SECTION I — PROVIDER INFORMATION
1. Name — Specialized Medical Vehicle Company
2. Wisconsin Medicaid Provider Number
3.
Date of Trip
(Eight Digits)
(MM/DD/YYYY)
4. Name — Driver (Last, First, Middle Initial)
5. SIGNATURE — Driver
6. Vehicle Identification or License Plate
7.
Name — Second Attendant (Last, First, Middle Initial)
8. Prescription for Second
Number
Attendant?
! Yes
! No
SECTION II — MEMBER INFORMATION
9. Name — Member (Last, First, Middle
10. Member Medicaid Identification
11. Wheelchair or
12. Cot or Stretcher?
Initial)
Number
Scooter?
! Yes
! No
! Yes
! No
SECTION III — ORIGINATING TRIP
13. Address — Dispatch Location (Number, Street, City, State, and ZIP Code)
14. Odometer Readings
15. Total Odometer
Unloaded Mileage
— Unloaded Mileage
Reading — Unloaded
Mileage
___________ Start
___________ End
16. Address — Pick-Up Point (Name of Facility, Number, Street, City, State, and
17.
Odometer Reading —
18.
Time — Trip Start
ZIP Code)
Trip Start
! a.m.
! p.m.
19. Address — Drop-Off Point (Name of Facility, Number, Street, City, State, and
20.
Odometer Reading —
21.
Time — Trip End
ZIP Code)
Trip End
! a.m.
! p.m.
22. Waiting Time
23. Waiting Time
24. More Than One Medicaid
25. Name — Primary Rider
26. Total Odometer
— Start
— End
Member in Vehicle?
Reading
! a.m.
! a.m.
! Yes
! No
! p.m.
! p.m.
SECTION IV — RETURN TRIP (Complete this section only if information in Sections I and II apply.)
27. Address — Dispatch Location (Number, Street, City, State, and ZIP Code)
28. Odometer Readings
29. Total Odometer
Unloaded Mileage
— Unloaded Mileage
Reading — Unloaded
Mileage
__________ Start
g
__________ End
30. Address — Pick-Up Point (Name of Facility, Number, Street, City, State, and
31. Odometer Reading
32. Time — Trip Start
ZIP Code)
— Trip Start
! a.m.
! p.m.
33. Address — Drop-Off Point (Name of Facility, Number, Street, City, State, and
34. Odometer Reading
35. Time — Trip End
ZIP Code)
— Trip End
! a.m.
! p.m.
36. More Than One Medicaid Member in
37. Name — Primary Rider
38. Total Odometer
Vehicle?
Reading
! Yes
! No
SECTION V — VERIFICATION OF MEDICAID-COVERED MEDICAL CARE (OPTIONAL)
39. Name (Printed) — Person Verifying Medicaid Covered Service
40. Position Title — Person Verifying Medicaid Covered Service
41. SIGNATURE — Person Verifying Medicaid Covered Service
42. Date Signed — Person Verifying Medicaid Covered Service
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