Provider Data Sheet Page 2
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2WISCONSIN CHRONIC DISEASE PROGRAM
Page 2 of 2
PROVIDER DATA SHEET
F-01146 (Rev. 12/03)
On behalf of ______________________________________________________________________("Provider"),
(Provider's Name is required)
the undersigned as an authorized representative of Provider, hereby agrees to the following conditions of participation for the
Wisconsin Chronic Disease Program ("WCDP"):
1.
Provider will comply with all applicable provisions of chs. DHS 152, 153, and 154, Wisconsin Administrative Code, and
that if it fails to comply with any such provision, the Wisconsin Department of Health Services ("DHS") may
terminate the Provider's participation in WCDP.
2.
Provider will submit claims for reimbursement through WCDP on forms designated by DHS, and must be signed by an
authorized representative of Provider, who certifies to the truthfulness, accuracy and completeness of the information
provided in the claim form.
3.
Provider will not claim reimbursement through WCDP by means other than submitting paper claims unless Provider is
approved by DHS for electronic claims submission, and that if Provider is approved by DHS for electronic claims
submission, the signature of the authorized representative below certifies to the truthfulness, accuracy and completeness
of all information submitted by Provider through electronic claims submission.
SIGNATURE - Authorized Representative of Provider
Date Signed
_______________________________________________________________________________________________________
SIGNATURE - Department of Health Services
Date Signed
_______________________________________________________________________________________________________
Return To:
WCDP
P.O. Box 6410
Madison, WI 53716
Provider Copy.
Please keep for your records.
RESET FORM
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