WI DHS F-01247 2017 free printable template
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The following are preferred drugs for members with the following HCV infection Genotype 1 Viekira Pak / Viekira XR or Zepatier Genotype 2 Epclusa Genotype 4 Technivie or Zepatier Note For Zepatier members with genotype 1a must be screened for the presence of NS5A polymorphisms. National Provider Identifier Prescriber 7. Address Prescriber Street City State ZIP 4 Code 8. Telephone Number Prescriber 9. Providers may refer to the Forms page of the ForwardHealth Portal at www. forwardhealth....
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How to fill out WI DHS F-01247
01
Obtain the WI DHS F-01247 form from the official Department of Health Services website or your local office.
02
Read the instructions carefully to understand the information required.
03
Fill in your personal details, including name, address, and contact information at the top of the form.
04
Provide information about your household members, including their names, ages, and relationships to you.
05
Indicate your income sources and amounts, including wages, benefits, or any other income.
06
Complete the questions regarding your expenses such as housing, utilities, and medical costs.
07
Review the form for any mistakes or missing information.
08
Sign and date the application at the bottom of the form.
09
Submit the filled-out form as instructed, either through mail, in person, or online if applicable.
Who needs WI DHS F-01247?
01
Individuals or families applying for financial assistance or services through Wisconsin's Department of Health Services.
02
Those seeking benefits such as FoodShare, Medicaid, or other state assistance programs.
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What is WI DHS F-01247?
WI DHS F-01247 is a form used by the Wisconsin Department of Health Services to document and report specific health-related information.
Who is required to file WI DHS F-01247?
Entities such as healthcare providers, organizations, and institutions involved in certain public health activities are typically required to file WI DHS F-01247.
How to fill out WI DHS F-01247?
To fill out WI DHS F-01247, one must provide accurate and complete information as per the guidelines outlined in the form, including demographics, health data, and any other required specifics.
What is the purpose of WI DHS F-01247?
The purpose of WI DHS F-01247 is to collect and compile essential health data to monitor public health trends, support health initiatives, and ensure compliance with state health regulations.
What information must be reported on WI DHS F-01247?
Information that must be reported on WI DHS F-01247 includes identification details of the reporting entity, patient demographics, health conditions, treatment received, and any relevant statistical data.
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