Form Dph 4818 – Fill Out and Use This PDF

Form Dph 4818 is a Centers for Medicare and Medicaid Services enrollment form designed to ensure that certain professions are correctly enrolled to bill correctly. The two types of positions requiring this form are medical transportation providers and medical social services professionals. It serves as an official document which verifies proper enrollment based on the submission's accurate information and completion. Completion of Form Dph 4818 makes sure that all taxonomic, credentialing, and other relevant information is provided for referencing purposes when service is rendered and billed through CMS'. It should be noted that Form Dph 4818 needs to be filed with any associated organization such as Medicaid or the local carrier fee for service or managed care plans where one has applied or intends to work with under Medicare billing privileges. Failure to complete this document accurately can have costly implications, so it requires careful attention.

Form Dph 4818 PDF Details

Form Dph 4818 is a document used to request information from the Department of Public Health about an individual or facility. This form can be used for a variety of purposes, including requesting information about an infectious disease, seeking records for an investigation, or requesting registration information for a facility. The Department of Public Health will typically respond to Form Dph 4818 requests within 30 days.

Question	Answer
Form Name	Form Dph 4818
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Wis, Underinsured, Rm, LCA

Form Preview Example

DEPARTMENT OF HEALTH AND FAMILY SERVICES	STATE OF WISCONSIN
Division of Public Health	s. 255.075, Wis Stats.

DPH 4818 (Rev. 06/01/08)

WISCONSIN WELL WOMAN PROGRAM (WWWP) ENROLLMENT

Read instructions on reverse prior to completing this form. Print clearly. Client information in this document is confidential under Wis. Stats 146.82

PERSONAL INFORMATION – Completed by Client

1. Last Name:

2. First Name:

Middle Initial:

Previous Last Name:

5. Street Address:

City:

7. State:

8. Zip:

County of Residence:

10. Native American Tribe:

11. Date of Birth:

(mm/dd/yyyy)

12.

Client Identification No.:

13. Social Security No.: (Optional)

14.

Day Telephone No.: (

)

15. Other/Cell Phone No.:

(

)

16. Mailing Address:

17.

City:

18. State:

19. Zip:

(If different from above)

20.Race: (check all that apply)

21. Ethnicity:

Hispanic / Latina


White	Black / African American
American Indian or Alaska Native
Non-Hispanic		Unknown

Asian Unknown

Native Hawaiian or Other Pacific Islander

22.	Emergency contact, not living with you:					23. Relationship:
24.	Address:		25. City:		26. State:			27. Zip:
28.	Contact Person’s Day Telephone No.: (	)		29. Other/Cell Phone No.:			(	)

INSURANCE INFORMATION – Completed by Client

30.Do you have Medicaid (including Family Planning Waiver)?

32. Do you have health insurance?

Yes

No	31. Do you have Medicare Part B?	Yes
	33. Do you have disability health insurance?

Yes

HEALTH CARE PROVIDER INFORMATION – Completed by Client

34.Do you have a primary health care provider?

36.Clinic Name:

Yes

No 35. If Yes, Name of Provider:

37.Street Address:

41.How did you hear about this program?

	38. City:
WWWP Coordinator	Relative / Friend
Clinic / Health Care Provider		Fair

	39. State:
Radio / TV	Newspaper
Billboard	Bus advertisement

40.Zip:

Brochure / Poster

Other

42.CLIENT PARTICIPATION AGREEMENT

I understand and agree to the following: the Wisconsin Well Woman Program (WWWP) will use the personally identifiable information only for program enrollment, program administration and case management. I give WWWP permission to release my medical information to the Local Coordinating Agency (LCA), other service providers, referral agencies and the State of Wisconsin. I understand that WWWP pays for preventive screening services, but does not pay for medical treatment services. I have seen the current program eligibility criteria and, to the best of my knowledge, my annual income does not exceed them. All of the information I have given is true and correct. I will inform the WWWP LCA if I move or if I no longer wish to participate.

I understand the enrollment is valid for one (1) year from the date signed.

43.	SIGNATURE – Applicant:	44. Date Signed:
45. SIGNATURE – Witness:		46. Date Signed:

Office Use Only

47.

Enrollment

Re-Enrollment

Dis-Enrollment

Date (mm/dd/yyyy):

Deceased

Date of death (mm/dd/yyyy):

48.

Certifying Agency No.:

49. Certifying Agency Name:

0. Enrollment Start Date (mm/dd/yyyy):

51. Enrollment End Date (mm/dd/yyyy):

52.

Age > 35:

Yes

53.

Income < 250% of Federal Poverty Level:

Yes

54.

Uninsured

55.

Underinsured

(See insurance info above)

56.

Translation services needed:

Yes

Language:

58. Household size:

Meets Eligibility Requirements

Eligibility Confirmed By:

61.

62. Printed name:

63. Signature:

FOR DANE COUNTY ONLY - Mail completed form to: WWWP - Public Health, 210 Martin Luther King Jr. Blvd., Rm. 507, Madison, WI 53703-3346

Form Dph 4818 – Fill Out and Use This PDF

Form Dph 4818 PDF Details

Form Preview Example

Form Dph 4818 isn’t the one you’re looking for?

Related Documents