Get Wi Dhs F-20418 2017-2026

The WI DHS F-20418 form is essential for Medicaid certified personal care providers seeking access to the web-based Personal Care Screening Tool. Completing this form accurately ensures timely access and facilitates effective communication among care agencies.

Follow the steps to complete the WI DHS F-20418 form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. In the first section, enter the 'Name - Medicaid Certified Provider' and your 'Medicaid Provider Number' accurately to establish your identity as a provider.
3. Provide the 'Name - Contact' along with the 'Telephone Number' and 'Email Address' for the primary contact person at your agency.
4. For the fields asking if the Medicaid certified provider will be performing personal care screens directly, select 'Yes' or 'No' based on your agency’s capabilities.
5. Indicate whether the provider is already established as an agency for Adult Long Term Care Functional Screen, Children’s Long Term Support Screen, and/or the Mental Health/AODA Screen by selecting 'Yes' or 'No'.
6. If contract agencies will be conducting personal care screens on behalf of your agency, select 'Yes' and provide the necessary details for each agency, including their name, contact information, telephone number, and email address.
7. List all agencies that will conduct personal care screens on your behalf. Ensure that you include the agency name, contact person, telephone number, and email address for each entry.
8. At the end of the form, complete the 'Submit Application to' section by providing the name and email address of the contact person to whom the application should be submitted.
9. Once all information is filled out, review the form for accuracy. You can then save any changes made, download the completed form, print it for your records, or share it as necessary.

Complete your application online today to ensure prompt access to the Personal Care Screening Tool.