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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11271 (12/09) STATE OF WISCONSIN DHS 106.13, Wis. Admin. Code WISCONSIN MEDICAID PERSONAL CARE PROVIDERS ADDENDUM

How to fill out personal care providers addendum

How to fill out personal care providers addendum:

1. Begin by carefully reading the instructions provided on the personal care providers addendum form. This will ensure that you understand the purpose and requirements of the document.
2. Fill in your personal information accurately and completely. This may include your full name, address, phone number, and any other relevant contact details.
3. Identify the individual for whom you will be providing personal care. Provide their name, date of birth, and any other necessary identification details.
4. Clearly state the scope of personal care services you will be providing. This may involve activities such as meal preparation, medication management, transportation assistance, or other specific tasks.
5. Indicate the number of hours or days per week you will be available to provide personal care services. Be specific to avoid any confusion or misunderstanding.
6. If you are employed by an agency or organization, provide the necessary details, such as the name of the agency and your job title.
7. If you are self-employed or work independently, provide any relevant documentation or licenses required in your jurisdiction.
8. Review the completed addendum form for any errors or omissions before submitting it. Make sure all fields are completed accurately and legibly.
9. Keep a copy of the filled-out addendum for your records in case it is needed in the future.

Who needs personal care providers addendum?

1. Individuals who require assistance with daily living activities due to age, illness, or disability may need to hire a personal care provider.
2. Family members who are responsible for the care of a loved one but need extra help or respite may also utilize personal care providers.
3. Organizations or agencies that provide in-home care services often require their employees or contracted caregivers to complete a personal care providers addendum to ensure compliance with regulations and accurately document the services provided.

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