Get Wi Medicaid Program Provider Agreementacknowledgement Of Term Sof Participation For Waiver Service

Filling out the Wisconsin Medicaid Program Provider Agreement Acknowledgement of Terms of Participation for Waiver Service is essential for providers offering home and community-based waiver services. This guide will provide clear and structured steps to complete the form online efficiently.

Follow the steps to complete the provider agreement online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the name of the provider exactly as it appears on other official documents. This ensures consistency and avoids any issues with processing.
3. Provide the telephone number of the provider in the designated field to facilitate communication.
4. Fill in the full street address, including city, state, and zip code of the provider to ensure accurate identification and correspondence.
5. Review the terms listed in the agreement, which outline the responsibilities and obligations of the provider towards the waiver services and participants.
6. Indicate if you wish to reassign the right to direct payment to the local waiver administrative agency by ticking ‘Yes’ or ‘No’ in the corresponding box.
7. Leave space for your signature and the date signed. Remember to print out the form to sign and date appropriately as it is required for validation.
8. Ensure that the waiver agency representative signs the form as well, which may also require them to type their name and provide the date signed.
9. After completing all sections, save your changes. Download, print, or share the completed form as needed.

Complete your forms online and ensure compliance with Wisconsin Medicaid requirements effectively.