SMV (Specialized Medical Vehicle) Transportation

Medicaid Pay Request Forms

In order to be covered by Wisconsin Medicaid the following three forms must be completed by the medical provider (physician, physician assistant, nurse midwife, nurse practitioner) and then faxed to SMART VAN at (715) 453-7432.
• SMV Certification of Need Request
• Form F-1197
• Form F-1197A

Private Pay Request Forms

Please print, fill out, sign and fax to us at (715) 453-7432
• SMV Private Pay Request

Please completely fill out and sign all forms and fax all completed forms to SMART Van at (715) 453-7432.