WI Becoming a Provider
Weds, Jan 26, 2022
Thank you for applying to become a provider for the Wisconsin Managed Care Organization.
Please fill out the fields below. All required fields are marked with "
Upon submitting this form, a contract specialist will contact you to further review your application.
Tax ID #:
(if different from above)
Hours of Operation:
Same as above:
will be sent
to this email)
Medicare & Medicaid
Part A #:
Part B #:
Has Handicap Parking
Infirm of Aging
Contracted Language Service
Population Over 60
Population Under 60
Deaf or Hearing Impaired
Traumatic Brain Injury
* denotes primary language
Is your agency a subsidiary of another agency (the parent)?
Limited Liability Company (LLC)
Limited Liability Partnership (LLP)
Fiscal Year Ending:
Date of Incorporation
Date Business Started:
(under present name)
Disadvantaged Business Enterprise (DBE):
State Minority Business:
Previous Business Name(s)
Has your company or any representative, owner, partner, or officer ever failed to perform awarded or had a contract terminated for failure to perform or for providing unsatisfactory service?
Please provide a detailed explanation:
Within the past five(5) years, has your company or any representative, owner, partner or officer (collectively "your company") ever been a party to any court or administrative proceedings where the violation of any local, state or federal statute, ordinance rule or regulation by your Company was alleged?
Please provide a detailed explanation outlining the following: date of citation; description of violation; parties involved; current status of citation
Within the past five(5) years, has your organization had any reported findings on an annual independent audit?
Please provide a detailed explanation.
Within the past five(5) years, has your organization been required to submit a corrective action plan by virtue of review or audit by independent auditor, or any govermental agency or purchaser of services?
Please provide a detailed explanation including if the corrective action has been accepted by the purchasing agency and completely implemented. If not, please explain remaining action required by purchasing agency.
Have you, any principals, owners, partners, shareholders, directors, members or officers of your business entity ever been convicted of, or pleaded guilty, or no contestto, a felony, serious or gross misdemeanor, or any crime or municipal violation, involving dishonesty, assault, sexual misconduct or abuse, or abuse of controlled substances or alcohol, or are charges pending against you or any of the above persons for any such crimes by information, indictment or otherwise?
Please provide a detailed explanation.
Experience / Service Proposal
Add each service you provide or are proposing to provide.
(please select populations served first.)
(in 2 yrs.)
Adult Day Care
Adult Family Home 1-2 Beds
Adult Family Home 3-4 Beds
Air Conditioner Supplier
CBRF (21-100 Beds)
CBRF (5-8 Beds)
CBRF (9-20 Beds)
Daily Living Skills
Day Program Supportive Work
Daycare Catheter Svcs
Health Fitness Program
Home Delivered Meals
Home Health Care Agency
Independent Living Arrangement
Licensed Practical Nurse
Licensed Psychologist (PHD)
NH 1-49 Beds
NH 50-74 Beds
NH 75-100 Beds
Personal Care Agency
Personal Emergency Response Systems
Residential Care Apartment Complex
Supportive Home Care
Wound/Ostomy/Continence Specialist (RN)
for this service:
Are you applying to
provide this service?
Do you currently provide this service?
How long have you been providing this service?
For this service, how many clients
are you able to serve at a time?
How many clients do you currently serve for this service?
For this service, what would be the
projected capacity w/in the next 2 yrs.?
What Agencies/organizations have referred business to you over the past three(3) years?
List any agencies/organizations with whome you have had contractual relationships within the previous three(3) years:
A narrative description of your agency and the services provided. Include a program summary, information about your experience, a description of your agency Quality Assurance program, and your operational policies and procedures. Specify your rate expectations for services provided to My Choice Off Shore. Finally, describe anything that you feel separates you from other agencies providing these services.
Board of Director Composition:
A list of all members of the Board of Directors, as well as officers, partners or owners. Include their titles and phone numbers.
When applicable, submit a copy of all license(s) or certification(s) issued to the agency by the State of Wisconsin or Milwaukee County, corresponding to the service(s) the agency is applying for, such as Adult Day Care, Group Home, Foster Care, Residential Licenses.
Please sign the Attestation Certificate.
If awarded a contract with My Choice Off Shore, agency must provide a Certificate of Insurance matching the requirements listed at the end of this application.
Criminal Background Checks:
Criminal Background Checks (CBCs) are required for all employees who work with or may come into contact with members. The background check must meet the standards set forth in the State of Wisconsin Caregiver Law, ss.50.065 and ss.146.40 Wis. Stats. and HFS 12 and HFS 13, Wis. Admin. Code State of Wisconsin Caregiver Program.
Equal Opportunity Certificate and Equal Opportunity Policy:
Agencies having a Milwaukee County contract with 50 or more employees shall develop and/or update an Affirmative Action Plan which will be made available upon request.
Civil Rights Compliance Plan:
Agencies which have a Milwaukee County contract shall have a Civil Rights Compliance Action Plan which ensures that no person shall, on the grounds of race, color, national origin, age, sex, religion, or handicap, be excluded from participation in or be subjected to discrimination in any program or activity funded, in whole or in part, by Federal and State funds.
Provider Assurances and Certifications
, agree that all information included in this application is true and correct and that the provider understands and agrees to the application information and requirements. Provider further acknowledges that the information in this application is subject to periodic verification without notice and that any misrepresentation on this form may result in disqualification from receiving public (CMO) funds and legal action or fiscal sanctions may be taken as determined appropriate by Milwaukee County or its designated representative(s). Provider understands that completion of provider application does not guarantee network admission and/or subsequent contract with the CMO.
, agree to allow authorized representatives of Milwaukee County Department of Family Care and itís funding sources, to have access to all records necessary to confirm the provision of services by the Provider. Failure on the part of the Provider to comply with program requirements, or not have sufficient documentation to verify provision of the services billed, may result in withholding or forfeiture of any payments. Providers must have client records as outlined in the CMO contract, that minimally include: names and address, the type and dates of service provided, the number of units of service provided, and documentation that service was provided. The applicant certifies to the best of its knowledge and belief, that it and its principals: (1) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (3) are not presently indicted for or otherwise criminally charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in (2) of this certification; and , (4) have not within a three-year period preceding this application had one or more public transactions (Federal, State or local) terminated for cause or default.
Checking this checkbox means that you are signing this form.
Provider agrees to evidence and maintain proof of financial responsibility to cover costs as may arise from claims of tort and/or vicarious liability due to its actions or omissions or the actions or omissions of its employees. Such evidence shall include insurance coverage for Worker's Compensation claims as required by the State of Wisconsin, including Employers Liability, and Business Insurance covering general liability and automobile coverage in the following minimum amounts, or in the amounts stated in WI Stats:
Type Of Coverage
Wisconsin Workers Compensation
Statutory or Proof of All States coverage
Commercial General Liability
Bodily Injury & Property Damage
(Incl. Personal Injury, Fire Legal Contractual & Products/Completed Operations)
$1,000,000 Per Occurrence
$1,000,000 General Aggregate
Bodily Injury & Property Damage
All Autos-Owned, non-owned
and/or hired Uninsured Motorists
$1,000,000 per Accident
Per Wisconsin Requirements
Comprehensive Crime Coverage
To include Fidelity, Theft, Money & Securities,
Inside & Outside to protect the loss of funds
by embezzlement, theft, fire, etc.
$5,000 Money and Securities
County shall be named as Additional Insured, As Its Interests May Appear, and be afforded a thirty (30) day written notice of cancellation or non-renewal. A certificate indicating the above coverages shall be submitted for review and approval by County for the duration of this Contract.
Coverageís shall be placed with an insurance company approved by the State of Wisconsin and rated "A" per Best's Key Rating Guide. Additional information as to policy form, retroactive date, discovery provisions and applicable retentions, shall be submitted to County if requested, to obtain approval of insurance requirements. Any deviations, including use of purchasing groups, risk retention groups, etc., or requests for waiver from the above requirements shall be submitted in writing to the County for approval prior to the commencement of activities under this Contract.
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