Wisconsin services 00309 medicaid form sample 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Medicaid Certified Agency/Organization' section. Enter the type of organization, such as County Social/Human Service Department or Independent Living Center, and provide the name and Medicaid Provider Number.
3. Next, complete the address fields. Ensure you accurately input both the physical and mailing addresses, including city, state, and zip code.
4. In the 'Name – Contact Person' field, enter the contact person's name along with their telephone number, email address, and fax number for any necessary follow-up.
5. Proceed to the 'Owner of Agency/Organization' section. Here, indicate the name of the agency owner and their mailing address details.
6. For geographical service areas, list all counties served by your personal care services. If applicable, indicate if your county is no longer providing these services by signing and dating at the bottom.

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