DHS WISCONSIN
DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F (04/2011) STATE OF WISCONSIN Bureau of Long-Term Support Children's Services Section 42 CFR 431.107 THIRD PARTY ADMINISTRATION (TPA) CHILDREN'S MEDICAID WAIVERS PROVIDER BILLING AND SERVICE INFORMATION Completion of this form is voluntary. However, providers must submit all information on this form to each county agency that has agreed to authorize children's Medicaid waivers services, and the agency is responsible for submitting this information to the Department of Health Services (DHS), Bureau of Long-Term Support (BLTS) MoreHowever, providers must submit all information on this form to each county agency that has agreed to ... License Expiration/Renewal Date (mm/dd/ccyy) ... Less
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