Form F-01185 - Wisconsin Adult Cystic Fibrosis Program Application - 2014 Page 5

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM

Page 5 of 5

APPLICATION

F-01185 (02/14)

SECTION 8. ADULT CYSTIC FIBROSIS PATIENT MEDICAL INFORMATION

Section 8 is to be completed by the medical director at an approved cystic fibrosis treatment center.

27. Name – Patient (Last, First, MI)

28. Patient’s primary diagnosis

(Use ICD-9-CM code)

Date Patient was diagnosed with cystic fibrosis _________________________ .

29.

30. Name – Treating Facility

31. Wisconsin Medicaid or BadgerCare Plus Provider

identification number of facility

32. Address – Treating Facility

I certify that the above patient has been diagnosed to have cystic fibrosis.

33. SIGNATURE – Medical Director

Date Signed

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.

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