Provider Data Sheet
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01146 (02/09)
WISCONSIN CHRONIC DISEASE PROGRAM
PROVIDER DATA SHEET
Wisconsin Chronic Disease Program requires information to enable the chronic disease program to certify providers to pay for
medical services provided to eligible recipients.
Personally identifiable information about Program providers is used for purposes directly related to the Program administration
such as determining the certification of providers or processing provider claims for reimbursement. Failure to supply the
information requested by the form may result in denial of payment for the services.
The use of this form is voluntary. However, in order to be certified, you must complete this form and submit it to the address
indicated.
INSTRUCTIONS: Complete this data sheet for whomever performed or will perform medical services for a Wisconsin Chronic
Disease Program participant.
Note: In order to be reimbursed for services provided in the Chronic Renal Program, Wisconsin Chronic Disease Program must
receive correct and complete claims, including resubmissions and adjustments, within 730 days from the date the service was
rendered. To be reimbursed for services provided in the Adult Cystic Fibrosis Program or Hemophilia Program, correct and
complete claims, including resubmissions and adjustments, must be received within 365 days from the date the service was
rendered.
1. Name — Provider
2. Telephone Number — Provider
3. Address — Provider (where services are rendered)
4. Name — Payee (to whom checks are made payable)
5. Address — Payee (where checks are to be sent)
o
6. Payee's:
Federal Identification / IRS Number ___ ___ - ___ ___ ___ ___ ___ ___ ___
o
Social Security Number ___ ___ ___ - ___ ___ -___ ___ ___ ___
7. Please check the appropriate box for a provider type.
o
Hospital
o
Pharmacy
o
Medical
___________________________________________
(indicate specialty)
o
Other
___________________________________________
(indicate specialty)
8. Medicare Number
9. Medicaid Number
10. License Number
I affirm that services provided are medically indicated and necessary to the patient's health. The services are within the scope of my
(our) licensure. I understand that any false claims, settlements, documents, or concealment of material fact may be prosecuted
under applicable federal and state law. I further affirm that to the best of my knowledge the information presented here is accurate
and complete.
SIGNATURE — Provider or Authorized Agent of Institution
Date Signed
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