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Get Wi Dhs F-00309 2012
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How to fill out the WI DHS F-00309 online
Filling out the WI DHS F-00309 form is essential for Medicaid providers in Wisconsin offering personal care services. This guide will walk you through the necessary steps to complete the form accurately and efficiently online.
Follow the steps to complete the form effortlessly.
- Click ‘Get Form’ button to access the form and open it for editing.
- Indicate the type of organization or agency by selecting from the options provided: County Social/Human Service Department, Independent Living Center, or American Indian Tribe/Band.
- Fill in the Medicaid provider number associated with your agency.
- Provide the name of your organization or agency that is registered as a Medicaid Provider.
- Enter the street address where personal care records are maintained, including the city, state, and zip code.
- Complete the mailing address if it differs from the physical address, again including city, state, and zip code.
- Identify a contact person within your organization, providing their name, telephone number, email address, and fax number.
- Identify the owner of the agency or organization by providing their name, mailing address, city, state, and zip code.
- List the geographical areas served by your personal care services by indicating the counties.
- If your county is no longer providing personal care services or billing under the Medicaid number, sign and date the form. Ensure the name of the Director is printed or typed for clarity.
- Once all fields are completed, save your changes, and consider downloading, printing, or sharing the form as necessary.
Complete your documents online today to ensure your information is accurately represented.
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To contact the Wisconsin Department of Health Services Media, you can visit their official website for the media inquiry form or find contact information for the press office. Engaging with the media department can provide insight and updates related to initiatives such as WI DHS F-00309, which may impact community health resources.
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