DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN

Division of Medicaid Services 42 CFR 431.107

F-01939 (02/2017)

F-01939 Page 3

WISCONSIN MEDICAID WAIVER PROVIDER REGISTRATION

Federal regulations require entities that are interested in being paid to deliver services funded by Medicaid waiver home and community-based services (HCBS) to register with the State Medicaid Agency and provide basic information about the owner of the business. Completion of this form is required for all providers interested in obtaining preliminary state approval to deliver services for the following Medicaid waiver programs:

·  Children’s Long-Term Support (CLTS) Waiver Program

·  Adult Waiver Services: Community Integration Program (CIP 1A/1B)

·  Adult Waiver Services: Community Options Program (COP-W/CIP II)

All interested providers must supply basic information about their services, capacity, and contact information, including: primary contact name, address, phone number, email address, the proposed geographic service area, and any special skills, experience or capacities in the sections listed below.

A1. Provider Contact Information
Business Name: / Click here to enter text.
Last Name: / Click here to enter text.
First Name: / Click here to enter text.
Address: / Click here to enter text.
Address 2: / Click here to enter text.
City: / Click here to enter text.
State: / Click here to enter text.
Zip: / Click here to enter text.
Phone Number: / Click here to enter text.
Email Address: / Click here to enter text.
Website: / Click here to enter text.
Include your name on the public Wisconsin Waiver Provider Registry? / ☐ Yes ☐ No
A2. Waiver Services: Select interest in delivering Adult or Children's waiver services (select all that apply)
☐ Adult waiver services
☐ Children's waiver services
☐ Both Adult and Children’s waiver services
A3. Provider Program Description
Include a brief program statement of no more than 250 words to describe the services you and/or agency staff are qualified to deliver, staffing capacity, such as the numbers of sites and capacity available in different locations. Include additional details if you and/or your staff have specialized training, skills or abilities, such as working with certain target populations, including individuals with physical or developmental disabilities, severe emotional or mental health conditions, or challenging behaviors, etc. If there are geographical limitations within a specified county, please include information here.
NOTE: DO NOT include any identity or health information regarding any specific person included in the disability target group description listed above, as this information is protected under federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 security and privacy regulations.
B1. Adult Waiver Services: Select population group(s) interested in serving (select all that apply)
☐ Adults with Developmental Disabilities
☐ Adults under age 65 with a Physical Disability
☐ Adults with a Serious and Persistent Mental Illness
☐ Adults with Traumatic Brain Injuries
☐ Elders (over 65)/Aging
B2. Adult Waiver Services: Select service(s) interesting in delivering from the list below (select all services that apply)
☐ Adaptive Aids - Vehicle Related / ☐ Nursing Services
☐ Adaptive Aids – Other / ☐ Peer/Advocates Supports
☐ Adult Day Care / ☐ Personal Emergency Response System
☐ Adult Family Home 1-2 bed / ☐ Pre-vocational Services
☐ Adult Family Home 3-4 bed / ☐ Relocation Related - Housing Start Up
☐ Benefit Counseling / ☐ Relocation Related – Utilities
☐ Communication Aids / ☐ Residential Care Apartment Complex
☐ Community Based Residential Facility / ☐ Respite Care - Home-Based
☐ Consumer and Family Directed Supports / ☐ Respite Care – Institutional
☐ Consumer Education and Training / ☐ Respite Care – Residential
☐ Counseling and Therapeutic Services / ☐ Respite Care - Other Setting
☐ Daily Living Skills Training / ☐ Short Term Supervision & Observation
☐ Day Services – Adults / ☐ Specialized Medical and Therapeutic Supplies
☐ Financial Management/Fiscal Intermediary Services / ☐ Specialized Transportation
☐ Home-Delivered Meals / ☐ Supported Employment
☐ Home Modifications / ☐ Supportive Home Care
☐ Housing Counseling / ☐ Vocational Futures Planning
☐ Housing Start Up / ☐ Vocational Recovery
B3. Adult Service Area: Select county/tribal area interested in delivering adult waiver service(s) (select all that apply)
☐ Adams County / ☐ Oneida County
☐ Dane County / ☐ Oneida Tribe
☐ Florence County / ☐ Taylor County
☐ Forest County / ☐ Vilas County
☐ Menominee Tribe

C. Registration Information (Children’s Waivers)

C1. Children’s Waiver Target Population: Select population group interested in serving (select all that apply).
☐ Children with Developmental Disabilities
☐ Children with Physical Disabilities
☐ Children with Severe Emotional Disturbance/Mental Health
C2. Select Children’s Waiver Services: Select service(s) interested in delivering from list below (select all that apply)
☐ Adaptive Aids - Vehicle Related / ☐ Housing Counseling
☐ Adaptive Aids – Other / ☐ Housing Start Up
☐ Children's Foster Care/Level 5 Exceptional Foster Care / ☐ Nursing Services
☐ Communication Aids / ☐ Personal Emergency Response System
☐ Consumer and Family Directed Supports / ☐ Respite Care - Home-Based
☐ Consumer Education and Training / ☐ Respite Care – Institutional
☐ Counseling and Therapeutic Services / ☐ Respite Care – Residential
☐ Daily Living Skills Training / ☐ Respite Care - Other Setting
☐ Day Services – Children / ☐ Specialized Medical and Therapeutic Supplies
☐ Financial Management/Fiscal Intermediary Services / ☐ Specialized Transportation
☐ Home Modifications / ☐ Supportive Home Care
C3. Children’s Service Area: Select county interested in serving; select all that apply or choose STATEWIDE option at end of list
☐ Adams County / ☐ Iowa County / ☐ Polk County
☐ Ashland County / ☐ Iron County / ☐ Portage County
☐ Barron County / ☐ Jackson County / ☐ Price County
☐ Bayfield County / ☐ Jefferson County / ☐ Racine County
☐ Brown County / ☐ Juneau County / ☐ Richland County
☐ Buffalo County / ☐ Kenosha County / ☐ Rock County
☐ Burnett County / ☐ Kewaunee County / ☐ Rusk County
☐ Calumet County / ☐ La Crosse County / ☐ Sauk County
☐ Chippewa County / ☐ Lafayette County / ☐ Sawyer County
☐ Clark County / ☐ Langlade County / ☐ Shawano County
☐ Columbia County / ☐ Lincoln County / ☐ Sheboygan County
☐ Crawford County / ☐ Manitowoc County / ☐ St. Croix County
☐ Dane County / ☐ Marathon County / ☐ Taylor County
☐ Dodge County / ☐ Marinette County / ☐ Trempealeau County
☐ Door County / ☐ Marquette County / ☐ Vernon County
☐ Douglas County / ☐ Menominee County / ☐ Vilas County
☐ Dunn County / ☐ Milwaukee County / ☐ Walworth County
☐ Eau Claire County / ☐ Monroe County / ☐ Washburn County
☐ Florence County / ☐ Oconto County / ☐ Washington County
☐ Fond du Lac County / ☐ Oneida County / ☐ Waukesha County
☐ Forest County / ☐ Outagamie County / ☐ Waupaca County
☐ Grant County / ☐ Ozaukee County / ☐ Waushara County
☐ Green County / ☐ Pepin County / ☐ Winnebago County
☐ Green Lake County / ☐ Pierce County / ☐ Wood County
☐ STATEWIDE
Name – Provider Agency Owner (Typed or Printed)
/ Title
SIGNATURE – Provider Agency Owner / Date Signed
Waiver Agency Representative (Typed or Printed)
/ Date Signed
SIGNATURE – Waiver Agency Representative

Submit the completed and signed Medicaid Waiver Provider Registration form by email to the DHS Provider Registry email box at .

Waiver providers must also complete the DHS Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Entities form prior to the approval and authorization to deliver services by the local waiver agency. For more information about Wisconsin’s HCBS waiver providers requirements, including access to the HCBS Waiver Program Manual and waiver provider forms, see the HCBS Waiver Provider Requirements webpage at: https://www.dhs.wisconsin.gov/waivermanual/provider.htm.