STATE OF WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES Division of Family and Economic Security AT R 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's full name and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Next, input the estimated delivery date. This helps determine eligibility for the W-2 ARP placement.
4. Indicate whether the patient has a high-risk pregnancy by selecting 'Yes' or 'No'. If 'Yes', provide details on the cause of the high-risk status in the comments section.
5. If applicable, specify if the high-risk pregnancy prevents the patient from working. Enter the start date for this inability to work if it occurred before signing this form.
6. Complete any additional comments that may assist in clarifying the patient's situation as noted by their physician.
7. Select the physician's specialty area and enter their National Provider Identifier (NPI).
8. Finally, ensure that all required signatures are provided, including the physician’s signature and date, along with their contact information.

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