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Specialized medical vehicle driver information chart f 01301

Specialized medical vehicle driver information chart f 01301 2025

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The document is a mandatory form from the Wisconsin Department of Health Services for specialized medical vehicle drivers, requiring specific information to authorize and reimburse medical services for eligible Medicaid members. It includes sections for driver and company details, licensing information, training certifications, and a signature affirmation of accuracy.

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Click ‘Get Form’ to open the specialized medical vehicle driver information chart f 01301 in the editor.
Begin by entering the name of your Specialized Medical Vehicle (SMV) Company in the designated field at the top of the form.
Next, provide the complete address of your SMV Company, including street, city, state, and ZIP+4 code.
Fill in your Provider ID in the appropriate section to ensure proper identification within the Wisconsin Medicaid system.
Enter the driver's name as it appears on their driver's license, followed by their driver's license number and expiration date.
Indicate whether the driver holds a regular or commercial license by selecting the appropriate option.
Document any first aid course details, including course name and date completed. Ensure all restrictions are listed clearly.
Provide dates for CPR training and any ramp/lift/restraint training as required.
Finally, have the person completing this form sign it, print their name and position title, and include the date signed.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (299 Votes)

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