Get the free my choice wisconsin provider refund form 100120
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MY CHOICE WISCONSIN CLAIM REFUND
Providers may send this completed form to the following address:
MCG Molina
ATTN: Refunds
5117 W Terrace Dr. STE 100
Madison, WI 53718
INSTRUCTIONS: Type or print
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What is my choice Wisconsin provider?
The My Choice Wisconsin Provider is a program that allows individuals to choose their own caregivers and service providers for long-term care services under Medicaid.
Who is required to file my choice Wisconsin provider?
Individuals who wish to receive long-term care services through the My Choice Wisconsin program must file this provider application.
How to fill out my choice Wisconsin provider?
To fill out the My Choice Wisconsin Provider application, individuals should complete the required forms available on the My Choice Wisconsin website and submit them along with any requested documentation.
What is the purpose of my choice Wisconsin provider?
The purpose of the My Choice Wisconsin Provider program is to enhance choice and control for Medicaid participants over their long-term care services by allowing them to select their own providers.
What information must be reported on my choice Wisconsin provider?
The information required includes personal identification details, service preferences, caregiver qualifications, and any relevant medical or financial information.
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