In order to accurately report your income and pay the correct amount of taxes, it is important to understand which tax forms you need to complete. The Form F 01020 is used by employers to report wages paid to employees and withheld taxes. In this blog post, we will provide a brief overview of the Form F 01020 and explain how it is used. We will also discuss some of the common mistakes that taxpayers make when completing this form. If you have any questions about the Form F 01020 or any other tax form, please contact our office for assistance. Thank you for reading!
| Question | Answer |
|---|---|
| Form Name | Form F 01020 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Identifier, Taxonomy, Wis, DHS |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Long Term Care |
DHS 107.09(4)(h), Wis. Admin. Code |
|
FORWARDHEALTH
REQUEST FOR NURSING HOME CARE DETERMINATION
INSTRUCTIONS: Type or print clearly. Before completing this form, refer to the Request for Nursing Home Care Determination Completion Instructions,
SECTION I — PROVIDER INFORMATION
1. Name — Billing Provider (Practice Location)
2. National Provider Identifier (Required)
3. Taxonomy Code (Required)
4. ZIP+4 Code
5.Billing Provider’s Medicaid Provider Number
6.Address — Billing Provider (Street, City, State, ZIP+4 Code)
7. Name — Nursing Home Contact Person
8. Telephone Number — Nursing Home Contact Person
SECTION II — MEMBER INFORMATION
9. Select One
New or Initial Request |
Revised Start Date (Element 15) |
Added or Revised Discharge Date (Element 16) |
10. Name — Member (Last, First, Middle Initial)
11. Member Identification Number (Required)
12. Social Security Number — Member
13. Date of Birth — Member
14. Gender — Member
Male |
Female |
15.Requested Start Date for Nursing Home Authorization Segment
16. Nursing Home Discharge Date
17.Minimum Data Set (MDS) Admission Assessment Submittal
An MDS Admission Assessment will be submitted to the Centers for Medicare and Medicaid Services (CMS) MDS system.
An MDS Admission Assessment will not be submitted to the CMS MDS system.
For cases where an admission assessment will not be submitted to CMS (i.e., for a short term stay [13 days or less]), providers are required to submit a copy of the following with this form:
•Physician’s orders admitting the member to the nursing home.
•All nursing medical notes.
•Discharge summary.