Provider Application Packet

If you are an individual or business serving people with long-term care needs and would like to be considered to serve as a Community Care provider, please complete the forms below.

Checklist of materials to send:

• Application
• W-9
• Data Collection Form - Fiscal (to be completed by all corporate residential providers)
• Data Collection Form - Scheduling (to be completed by all corporate residential providers, 8 beds or fewer)
• Data Collection Form - Indirect Overhead
• All Licenses and/or Certifications
• Insurance Declaration Pages
• Direct Deposit Form

Applications

General Application - all providers EXCEPT Certified Adult Family Homes

• Microsoft Word format (preferred) and PDF format.

Residential Summary

• Complete this form in addition to the General Application.

Certified (1-2 Bed) Adult Family Home Application Process

• Certified Adult Family Homes (AFH) must begin the contracting process by contacting the Community Care AFH Department at: 866-937-2783 or AFH.Certification@communitycareinc.org

Form W-9

Filling out a W-9 is pretty straightforward. Just provide your name and Social Security Number, or the name and Employer Identification Number of your business. By submitting a W-9, you are certifying that the tax id number you are providing is correct and accurate and that you are not subject to backup withholding.

To download Form W-9 and filing instructions, click here.

To select and download additional related IRS forms and filing instructions, click here

Data Collection Forms

• Fiscal (all corporate residential facilities)
• Scheduling (all corporate residential facilities 8 or fewer beds)
• Indirect Overhead

Direct Deposit Form

• Direct Deposit form (.pdf format)

To submit your application:

Fax:
(262) 446-6707

OR

Mail:
Community Care
ATT: Provider Management
1801 Dolphin Drive
Waukesha, Wisconsin 53186