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Get Wi Dhs F-00309 2018-2026
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How to fill out the WI DHS F-00309 online
The WI DHS F-00309 form is essential for collecting information from Medicaid personal care providers in Wisconsin. This guide provides clear, step-by-step instructions for filling out the form efficiently and accurately online.
Follow the steps to complete the form online:
- Click ‘Get Form’ button to obtain the form and open it for completion.
- Identify the type of organization you are representing. Choose from County Social/Human Service Department, Independent Living Center, or American Indian Tribe or Band.
- Enter the name of your organization or agency in the designated field.
- Input your Medicaid Provider Number, which is required for identification.
- Fill in the physical address where personal care records are maintained. Ensure you include the street address, city, state, and zip code.
- Provide the mailing address if it differs from the physical address. Again, include the city, state, and zip code.
- Enter the name of the contact person, including their telephone number, email address, and fax number.
- Indicate the Owner of the Agency or Organization. This includes entering the name of the County Department of Human Services Director or Tribal Chairperson, along with the mailing address including city, state, and zip code.
- Specify the geographical area of personal care services by indicating the counties served.
- If applicable, note if your county is no longer providing personal care services or billing under your Medicaid number. Complete the signature section, including the Director's signature, the date signed, and the printed name of the Director.
- Once all fields are filled, review the form for accuracy. You can save changes, download, print, or share the completed form as needed.
Start completing the WI DHS F-00309 online today!
To establish residency in Wisconsin, you typically need to live in the state for at least 12 months, although specific rules may apply based on your situation. This residency timeframe is important for accessing benefits like those governed by WI DHS F-00309. For more detailed inquiries, you may want to consult local agencies for assistance.
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