Appendix 1 Wisconsin Medicaid-Allowable Family Planning Procedure Codes & Descriptions
Appendix 2 Medicaid Type of Service & Place of Service
Appendix 3 Second Opinion Elective Surgery Request/Physician Report
Appendix 4 Abortion Certification Statements (PDF, 53 KB)
Appendix 5 Acknowledgement of Receipt of Hysterectomy Information (PDF, 39 KB)
Appendix 6 Sterilization Informed Consent Form Instructions
Appendix 7 Sterilization Informed Consent
Appendix 8 CMS 1500 Claim Form Completion Instructions
Appendix 9 CMS 1500 Claim Form Sample for Family Planning Clinic Service
Appendix 10 McKesson ClaimCheck®
Appendix 11 Breast Pump Order (PDF, 48 KB)
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