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NEW FORMS FOR 2017
For forms related to changes going into effect on January 1, 2017, please go to the Business System 2017 page.
Provider Information Updates
Checklist for All Adult Family Home (AFH) and 5-8 Bed Community Based Residential Facility (CBRF) Care Management Visits This form is completed by care managers at the time of member reviews.
Prevocational Services Six-Month Status and Progress Report To be completed by the authorized prevocational services provider. This report is due to the member's care manager at two points in each calendar year:
Residential Assessment FormThis form is completed by ContinuUs providers who have new ContinuUs enrollees that already reside in their non-nursing home residential setting at the time of the member's enrollment with ContinuUs. Residential Rate Setting Assessment Tutorial for Providers
Unintended Events Report Form All individuals or entities providing services to ContinuUs members are required to report unintended member incidents and events to the Care Management Team within 24 hours from the time the provider becomes aware of the incident/situation. See Member Incidents section in the ContinuUs Provider Handbook for more information.
Provider Comment FormTo comment about a provider that you feel has gone above and beyond in service provision, please complete a Provider Comment Form. Then print the form and mail or fax it to the address on the form. This form can also be used to alert us if you have quality or other concerns relating to a specific provider. The forms are submitted to ContinuUs Provider Services staff for processing and follow-up.
W-9 Form (Request for Taxpayer Identification Number) Click the link above to go to the IRS site for the W-9 form. You can fill this form out on your computer, and then print and mail or fax it to us. Adult Family Home and CBRF providers must also complete the Adult Family Home/CBRF Additional Tax Information Form.
Provider Succession PlanAdult Family Home (AFH), CBRF, and Supportive Home Care providers are required to have a succession plan on file with ContinuUs. It is essential that you have a plan to keep residents safe and employees secure, if you were temporarily (or permanently) unable to return to operate your business. This form provides ContinuUs with information we need to work with your “successor” if this should occur. Please submit a new form if your information changes.
Claims and Billing Information
Provider Application and Contracting
Administration Office28526 US Hwy 14Lone Rock, WI 53556P: 608-647-4729 F: 608-647-4754