Fillable State of wisconsin third party administrator license form
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...
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