Home and Community-Based Services Waiver - Provider Information

Waiver Provider Registration: If you are a provider interested in registering for approval to deliver HCBS waiver services for programs serving adults or children, please complete the online Wisconsin Medicaid Waiver Provider Registration process.

Medicaid Waiver Provider Agreement forms: If you are a provider interested in completing the Wisconsin Medicaid Waiver Provider Agreement, the following agreement forms have been developed, each designed for a specific provider type:

  • Form F-00180 (Word) is for Medicaid waiver service provider organizations. Organizations include waiver providers such as personal care agencies, adult or child day care agencies, supportive home care agencies, transportation agencies, and other organizations or agencies that have been specifically identified as covered service providers.
  • Form F-00180A (Word) is for providers who are individual, sole proprietors, unaffiliated with an agency or service organization. It is also to be used for a company that provides waiver-funded services not typically covered by Medicaid providers. Examples include carpenters and other skilled trades completing home modifications or specialty work such as vehicle modifications.
  • Form F-00180B (Word) is used for provider agencies or individuals who are employed by the waiver participant under a self-directed support and service plan and paid through a fiscal agent or fiscal intermediary.

Providers interested in approval must complete and sign the appropriate Medicaid Waiver Agreement. Submit the completed Medicaid Waiver Agreement electronically to DHSProviderRegistry@dhs.wisconsin.gov.

Please contact the DHS Provider Registry with questions.

Last Revised: June 16, 2017