Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10148 (10/08)

STATE OF WISCONSIN

APPLICATION TO BECOME A CERTIFIED PARTNER / PROVIDER FOR BADGERCARE PLUS EXPRESS ENROLLMENT FOR CHILDREN This is an application to become a partner/provider certified to use the BadgerCare Plus Express Enrollment Web based tool to temporarily enroll children in BadgerCare Plus. If this application is approved, you will receive an approval letter with your partner/provider number and information on how to temporarily enroll children in BadgerCare Plus using Express Enrollment. In addition, you will receive a letter containing your one-time use personal identification number (PIN) for purposes of logging in and setting up administrative rights for individuals in your agency to access the online express enrollment tool. Complete the information below, sign and date this form, and fax or mail it to: Provider Maintenance 6406 Bridge Rd Madison WI 53784 (608) 221-0885 (Fax) Name -- Organization / Agency Address FEIN/TIN Telephone Number ( ) FAX Number City Type of Organization (Check all that apply.) Medicaid Certified Provider National Provider Identifier Head Start WIC Program Community Based Organization State ZIP Code

Emergency Food and / or Shelter Provider Elementary or Secondary School Government Entity / Tribal Organization Faith-Based Organization Other (Describe)

Note: The Security Administrator will receive the PIN instructions for setting up users in your organization/agency. SECURITY ADMINISTRATOR Name -- First Telephone Number ( ) INDIVIDUAL COMPLETING THIS FORM Name -- First Telephone Number ( ) MI Last E-mail Address Date
Continued

MI

Last E-mail Address

Title

If the individual completing this form is not the Security Administrator, provide the information below. Title

SIGNATURE -- Individual Completing Form / Security Administrator

APPLICATION TO BECOME A CERTIFIED PARTNER / PROVIDER FOR BADGERCARE PLUS EXPRESS ENROLLMENT FOR CHILDREN F-10148 (10/08)

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Complete this section if you are requesting certification for more than one site/location. Primary Site Name Address Telephone Number (Include Area Code)

City

State

ZIP Code

Please provide a unique identifier for each additional site. For example: Health Care Clinic -- "East Side, Main Street." Site Name Address Telephone Number ) (

City

State

ZIP Code

Site Name Address

Telephone Number ( )

City

State

ZIP Code

Site Name Address

Telephone Number ( )

City

State

ZIP Code