Wisconsin Works (W-2) offers an At Risk Pregnancy placement with payment and services for an unmarried pregnant woman who has no minor children in her custody and cannot work because of a high-risk pregnancy. This form is the medical verification: the physician confirms the due date, that the pregnancy is high risk and that it prevents work, based on an exam within four months of the due date.
The patient's physician completes the whole form after examining her, including due date, high-risk status, cause, start date of inability to work, specialty, NPI and signature. The W-2 agency fills in its contact details at the top.
Download the current version from the source each time; forms change without notice.
At Risk Pregnancy (ARP) Medical Information/Verification
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
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Three things: that the patient is in the third trimester based on her due date, that the pregnancy is high risk, and that the high-risk pregnancy leaves her unable to work, in the physician's best determination. The physician also states the cause of the high-risk status and when the inability to work began.
Yes. DCF accepts all of the same items written on the physician's letterhead instead of the form. The letter still has to come from the patient's physician and reflect an examination within four months of the due date, and it goes to the same W-2 agency.
An unmarried pregnant woman with no dependent minor children in her custody at home, who has medical verification of a third-trimester, high-risk pregnancy that prevents her from working. The W-2 agency makes the eligibility decision; the physician supplies only the medical verification.