CDCP Employer Application

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CDCP Application Type

Contact Type

Agency/Facility/IRIS Participant Name/CLTS Participant Name/Family Care SDS Participant

Physical Address

Address Line 2

City

State

Zip Code

Facility Website - If you do not have a website - please put n/a.

Provider License Number

If your entity/company does not have a provider license number, write 'NONE'

Entity Type:

Other, please specify

Which MCO provider networks are you a part of? (select all that apply)

Community Care, Inc. iCareInclusaLakeland Care My Choice WisconsinNoneOther

Other, please specify

Which Medicaid Programs do you contract with? (select all that apply)

Children’s Long-Term SupportFamily CareFamily Care PartnershipIRISPACENoneOther

Other, please specify

What type of entity/provider are you? (select all that apply)

1-2 Certified Adult Family Home (AFH)3-4 Bed Adult Family Home (AFH)Certified Adult Day CareCommunity-Based Residential Facility (CBRF)Home Health AgencyMicroboardPersonal Care AgencyResidential Care Apartment Complex (RCAC)’Skilled Nursing FacilitySupportive Home Care AgencyIRIS ParticipantCLTS ParticipantFamily Care SDS ParticipantSubstance Abuse Program (DHS 75.53 and/or 75.54)Other

Other, please specify

If CLTS, how are you affiliated (check all that apply)

Financial Management Services (FMS)CLTS Provider/AgencyCounty Waiver AgencyParent or Guardian Other

Name of Financial Management Services (FMS)

Name of Provider/Agency

Name of Agency

Name of Parent/Guardian

Please explain further

Do you have a legal entity?

YesNo

Legal Entity Information

Legal Entity Name

Owner, licensee, or legal entity used for licensure, certification, or registry

Legal Entity Contact First Name

Legal Entity Contact Last Name

Legal Entity Phone Number

Legal Entity Email Address

Legal Entity Mailing Address

Legal Entity City

Legal Entity State

Legal Entity Postal Code

For help with the CDCP Training Registry, please contact us at:
 
Phone: 920-465-2315 or Email: cdcp@uwgb.edu

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Please enter the information of the contact person, and one alternate contact person, at your agency or facility below.

Contact Person First Name

Contact Person Last Name

Contact Person Title

Contact Person Phone Number

Contact Person Email Address

Alternate Contact First Name

Alternate Contact Last Name

Alternate Contact Person Title

Alternate Contact Phone Number

Alternate Contact Email Address