AFH CERTIFICATION REQUEST AND PROVIDER APPLICATION (for 1-2 bed AFH)
Family Care Partnership Services
INSTRUCTIONS: Independent Care Health Plan (“iCare”) is a Family Care Partnership Program Managed Care Contractor (http://dhs.wisconsin.gov/wipartnership) in Milwaukee, Racine and Kenosha County. The iCare Network expansion process is guided by the following values:
Offering the broadest range of choices to prospective consumers Recognizing the need for continuity of care wherever possible Ensuring the availability of credentialed and licensed providers as required Rewarding cost and service efficiencies
All interested 1-2 bed AFH providers will be considered for iCare network participation and a contractual relationship upon completion of the iCare AFH Certification Process. Type or print your information on this application. Providers will note that completion of the certification does not guarantee contracted participation in the iCare network and will not include a guarantee of utilization or exclusivity. To begin the iCare AFH Certification Process, please complete this form. A signature and date is required. Please remit the completed form and the non-refundable certification fee of $400 per location to iCare, 1555 RiverCenter Drive, Suite 206, Milwaukee, WI 53212: Attn: AFH Certification Application.
Upon receipt of the completed application and certification payment, iCare will review the application for completeness. If the application is incomplete, both the application and payment will be sent back to provider for a complete application. iCare will forward the completed application to Lutheran Social Service (LSS) who is contracted to complete the certification review on behalf of iCare. LSS will contact the AFH provider and will 1.) request additional documentation to include Caregiver Background Checks and Program Statement and 2.) request an onsite inspection visit and 3.) provide orientation regarding the responsibilities of the AFH provider.
Once the certification review is completed by LSS, the provider’s certification application and the LSS review findings are shared with iCare Credential Committee. The Credential Committee will review the information and make a determination regarding certification. The decision of the Credential Committee will be communicated to the AFH provider.
Revised 9.15.2013 Page 1 SECTION I: Organizational Information: Please include a copy of W-9 and Liability Insurance Face Sheet
Provider Legal Name: Federal TIN or SSN:
Provider Street Address: Email address:
Provider City Address: State: ZIP:
Provider Phone Number: Provider Fax Number:
Contact Name:
Signor Name:
Billing Name:
Billing Address:
Counties Served: Population Served: Milwaukee Kenosha Frail Elderly Mental Illness Waukesha Washington Physical Disabilities AODA Racine Ozaukee Developmental Disabilities Dane
2 Section II: Service Location Information
Service Location Name: Target Population
Number of individuals served: Address (Street): City: State: ZIP:
Phone: Fax:
Service Location Name: Target Population
Number of individuals served: Address (Street): City: State: ZIP:
Phone: Fax:
Any previous certification denied or terminated: ____Yes: Please give detail of date of termination or NO____ denied certification or recertification
Service Description and procedure code Rate/Unit of Service: ______
Revised 9.15.2013 Page 3 Section IV: Assurances
By signing this Application, the respondent confirms that it (he/she) understands and assures the following:
The Signor below is authorized to represent the provider in this Application. This Application is not a contract for the utilization or provision of waiver services. The information provided in this Application is accurate, truthful and current. Upon successful completion of the certification process, the Provider wishes to receive a service contract that reflects mutual consent between the parties.
Authorized signature & title: Date:
Print signature & title:
4 Section V: Attestation
Agency attests that as it relates to the facilities and services above, it:
Has verified qualifications of each staff member, including academic preparation and relevant Yes No experience. Has proof of all permits, licenses and certifications, required of staff members, to perform the Yes No duties of their position. Maintains a training plan for each staff member and has a mechanism for ensuring that all Yes No necessary training has been completed prior to performing work. Completes Caregiver Background Checks on all employees prior to the employee providing direct services to Member, and every four (4) years thereafter or any time that entity has a Yes No reason to believe that a new check should be obtained. Has a mechanism to track the completion of Caregiver Background Checks to ensure Yes No compliance with the requirements in the iCare LTC contract. Maintains the results on its premises for at least the duration of the LTC contract with iCare. Yes No
The individual identified below acknowledges that they have reviewed the statements above and attests that the information herein be true and accurate. Signature: ______
Name: ______
Title: ______
Date: ______
Please return completed (signed and dated) Application and $400 per location certification fee to: Independent Care Health Plan (iCare) c/o AFH Certification Application 1555 RiverCenter Drive, Suite 206 Milwaukee, WI 53212
Revised 9.15.2013 Page 5