• General Information
  • Introduction
  • Provider Certification
  • Eligibility Criteria
  • Applications
    • Introduction
    • Obtaining Forms
  • Eligibility Verification
  • Duration of Benefits
    • Introduction
    • Extensions
  • Applying for Full-Benefit Medicaid
  • Covered Services
  • Claims
• Appendix
  • Appendix 1 — Instructions for Completing the Presumptive Eligibility for Pregnant Women Application
  • Appendix 2 — Sample Presumptive Eligibility for Pregnant Women Application
• PDF

General Information

Applications

Refer to Appendix 1 and Appendix 2 of this guide for the application completion instructions and a sample copy of the Presumptive Eligibility for Pregnant Women Application form, HCF 10081.

Upon completion, the PE provider is required to submit the application to Wisconsin Medicaid. Wisconsin Medicaid must receive the application within five working days after the determination is made. Providers should submit the application by fax to (608) 221-8815 (Please use [608] 250-5202 for faxing rather than the previously listed telephone number; for further information, refer to July 2003 Wisconsin Medicaid and BadgerCare Update 2003-68 titled "Family Planning Waiver Program policy additions and clarifications.") or by mail to the following address:

Wisconsin Medicaid
Presumptive Eligibility
6406 Bridge Rd
Madison WI 53784

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