Wisconsin Medicaid requires this certification before a member can use specialized medical vehicle (SMV) transportation to get to medical care. The evaluator confirms that a physical or mental impairment makes travel by mass transit, taxi or private vehicle unsafe, classifies the member as indefinitely disabled, legally blind or temporarily disabled, and explains why an SMV is needed.
Only a physician, physician assistant, nurse midwife or nurse practitioner may evaluate the member, complete Sections III and IV and sign with an original signature. The SMV provider gives the blank form to the member and keeps the completed original.
Download the current version from the source each time; forms change without notice.
Certification of Need for Specialized Medical Vehicle Transportation
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Only a physician, physician assistant, nurse midwife or nurse practitioner may act as the evaluator and sign F-01197. The signature must be original, not stamped or photocopied, and the evaluator must have evaluated the member and found that they cannot travel safely by common carrier.
For a member certified as indefinitely disabled or legally blind, it is valid for three years (36 months) from the date the evaluator signs. For a temporarily disabled member, it is valid for no more than 90 days, with the expected duration stated if shorter, and it may be renewed.
Yes. The completion instructions tell the SMV provider to accept the form only if it is received within 14 working days of the date the evaluator signed it. The provider keeps the completed original in the member's file for five years from the last date of service billed under it.