Get Wi Wps Health Insurance Facility Data Sheet 2016-2026

The WI WPS Health Insurance Facility Data Sheet is an essential form for notifying Arise Health Plan and WPS Health Insurance about any changes, additions, or terminations to facilities within your organization. This guide provides clear instructions for filling out the form online to ensure accurate and timely submission.

Follow the steps to complete your facility data sheet effectively.

1. Press the ‘Get Form’ button to access the necessary document and open it in your online editor.
2. In Section 1, provide your contact information. Include today's date, your name, organization, address, city, state, zip code, telephone number, and federal tax ID number.
3. Proceed to Section 2, the credentialing contact section. Fill out the fax number and email address. If your credentialing contact is the same as your contact information, check the box indicating this. Otherwise, provide the relevant details of the credentialing contact.
4. In Section 3, you will enter the facility information. Specify the location name and facility NPI. Choose the appropriate action from the options: add facility, term facility, or update facility. Fill in the corresponding section based on your choice.
5. If adding a facility, complete Section A with location street address, city, state, zip, county, telephone number, fax number, Medicare number, Medicaid number, and effective date. Also, include billing information: name on the 1099 tax form, federal tax ID, remit to name, and address.
6. For Section A, check all applicable facility types or services. Make sure to include details about the number of beds if applicable.
7. If terminating a facility, complete Section B, entering the facility name, address, city, state, zip code, and termination date.
8. If updating a facility, fill out Section C. Provide the previous facility name, address, phone number, and fax number, and note the effective date of the change.
9. Once all sections are completed, review the form for accuracy. Save your changes, and you may choose to download, print, or share the completed form as needed.

Complete and submit the WI WPS Health Insurance Facility Data Sheet online for effective facility management.