Free Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women, F10177 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10177 (10/08)

STATE OF WISCONSIN

APPLICATION TO BECOME A CERTIFIED PROVIDER FOR BADGERCARE PLUS EXPRESS ENROLLMENT FOR PREGNANT WOMEN
This is an application to become a provider certified to use the BadgerCare Plus Express Enrollment Web-based tool to temporarily enroll pregnant women in BadgerCare Plus. If this application is approved, you will receive information on how to temporarily enroll pregnant women in BadgerCare Plus. In addition, you will receive a 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 -- Provider Address -- Street City State

National Provider Identifier Telephone (Include Area Code) ZIP Code

To be eligible, providers must meet the criteria in Section I and in Section II or Section III. SECTION I Indicate the type of services you provide: Clinic AND SECTION II Indicate if you receive funding under the following (check all that apply): Community Health Centers or Migrant Health Centers Maternal and Child Health Title V Title V of the Indian Health Care Improvement Act WIC Program Commodity Supplemental Food Program OR SECTION III Indicate if your agency is: A state perinatal program An Indian Health Service A health program or facility operated by a tribe or tribal organization (i.e., a Section 638 facility or program)
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Outpatient Hospital

Rural Health Clinic

APPLICATION TO BECOME A CERTIFIED PROVIDER FOR BADGERCARE PLUS EXPRESS ENROLLMENT FOR PREGNANT WOMEN F-10177 (10/08)

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Note: The Security Administrator will receive the one time use PIN instructions for setting up users in your organization/agency. Name -- First Telephone Number ( ) MI Last E-mail Address Title

If the individual completing this form is not the Security Administrator, provide the information below. Name -- First Telephone Number ( ) MI Last E-mail Address Title

SIGNATURE -- Individual Completing this Form or Security Administrator

Date Signed

Complete this section if you are requesting certification for more than one site for this organization. Primary Site Name Address Telephone Number ( )

City

State

ZIP Code

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
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APPLICATION TO BECOME A CERTIFIED PROVIDER FOR BADGERCARE PLUS EXPRESS ENROLLMENT FOR PREGNANT WOMEN F-10177 (10/08)

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Site Name Address

Telephone Number ( )

City

State

ZIP Code

Site Name Address

Telephone Number ( )

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State

ZIP Code

Site Name Address

Telephone Number ( )

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State

ZIP Code

Site Name Address

Telephone Number ( )

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