Medicaid Targeted Case Management Face Sheet - Childhood ...
DEPARTMENT OF HEALTH SERVICESDivision of Public HealthF-44771AA (09/2019)STATE OF WISCONSINBureau of Environmental HealthWis. Stat. § 254.15Phone: 608-266-5817FAX: 608-267-0402MEDICAID TARGETED CASE MANAGEMENT FACE SHEET – CHILDHOOD LEAD POISONINGThis form should be completed when Medicaid Targeted Case Management will be provided to an eligible child. The face sheet provides documentation of additional assessments required for reimbursement for targeted case management that is not included on the Nursing Case Management Report, on Children with Elevated Blood Lead Levels, F-44771A.THIS PAGE DOES NOT NEED TO BE RETURNED TO THE WISCONSIN CHILDHOOD LEAD POISON PREVENTION PROGRAMCHILD INFORMATIONName of child receiving targeted case management FORMTEXT ?????Date of birth (mm/dd/yy) FORMTEXT ?????Medicaid Number FORMTEXT ?????OTHER PROVIDERS INVOLVED IN ASSESSMENT OF THE CHILDName and Title FORMTEXT ?????Role in the assessment FORMTEXT ?????Name and Title FORMTEXT ?????Role in the assessment FORMTEXT ?????Name and Title FORMTEXT ?????Role in the assessment FORMTEXT ?????OTHER HOUSEHOLD MEMBERS RECEIVING CASE MANAGEMENTName of client FORMTEXT ?????Name of Case Manager FORMTEXT ?????Name of client FORMTEXT ?????Name of Case Manager FORMTEXT ?????Name of client FORMTEXT ?????Name of Case Manager FORMTEXT ?????ENVIRONMENTAL ASSESSMENTDate of lead hazard investigation (mm/dd/yy) FORMTEXT ?????Lead hazard investigation report on file FORMCHECKBOX YesIdentify any other safety / health issues in the home that are to be addressed: FORMTEXT ?????FAMILY RESOURCESDental careDate of the last dental visit (mm/dd/yy)How many times per year does this child see the dentist? FORMTEXT ????? FORMTEXT ?????FinancialThe family reports not having enough money for:Assistance provided to the family to address family financial resources: FORMTEXT ????? FORMCHECKBOX Food FORMCHECKBOX Shelter FORMCHECKBOX Clothing FORMCHECKBOX Medical needsCommunityThe family would like more information on the following topics: FORMCHECKBOX Recreation FORMCHECKBOX Employment and training FORMCHECKBOX Health care FORMCHECKBOX Child development FORMCHECKBOX Parenting skills FORMCHECKBOX Coping with stress FORMCHECKBOX Family resource center FORMCHECKBOX OtherSIGNATURE - Medicaid Targeted Case ManagerDate Signed (mm/dd/yy) ................
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