Provider Application
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.
Provider ID:    Tax ID #:   
Applying Agency:

Address1:
Address2:
City: State:
Zip:
Phone Number: Fax Number:
Web Site:
Hours of Operation:
Same as above:
Address1:
Address2:
City: State:
Zip:
Last Name: First Name:
Title:
Phone:
Email:
Last Name: First Name:
Title:
Phone:

Medicare Certified
Part A #: Date Issued:
Part B #: Date Issued:
Medicaid Certified
Medicaid #: Date Issued:
Has Handicap Parking DD/TTY Number:
   
   
   
   
   
   
   
   
 
Is your agency a subsidiary of another agency (the parent)? 
Corporate Structure: Fiscal Year Ending:
Date of Incorporation
or Organization:		 Date Business Started:
Disadvantaged Business Enterprise (DBE): State Minority Business:
Previous Business Name(s) Start Date End Date  
1. 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?
2. 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?
3. Within the past five(5) years, has your organization had any reported findings on an annual independent audit?
4. 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?
5. 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?
Add each service you provide or are proposing to provide.
Service Populations
Served		 Applying
to Provide
this service?		 Currently
Providing
this Service?		 Years
Providing
Service		 Clients
Served
at a
Time		 Clients
Currently
Served		 Projected
Capacity
(in 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:
1. Agency Description:
  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.
 
2. 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.
 
3. Agency License:
  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.
4. Attestation Certificate:
  Please sign the Attestation Certificate.
5. Insurance Coverage:
  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.
6. 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.
7. 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.
8. 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.
I, , 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.

I, , agree to allow authorized representatives of Milwaukee County Department of Family Care and it’s 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. Date Signed: 4/26/2024
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 Minimum Limits
Wisconsin Workers Compensation Statutory or Proof of All States coverage
Employers Liability $100,000/$500,000/$100,000
Commercial General Liability
 $1,000,000 Per Occurrence
$1,000,000 General Aggregate
Automobile Liability
 $1,000,000 per Accident
Per Wisconsin Requirements
Comprehensive Crime Coverage
 $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.

Coverage’s 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.