Forms and Materials
New Provider Application
Fillable Application for Lakeland Care Provider (Residential or Non-Residential)
Paper Application for Lakeland Care Provider (Residential or Non-Residential)
Change in Condition Rate Change Requests
Nursing Homes
Nursing Home Bed Hold Request (electronic)
Nursing Home Bed Hold Request (paper)
Current Contract Addenda
Translation Interpreter Services
Personal Electronic Monitoring and Response Services
Financial Management Services-SDS
Residential Care Apartment Complex
Required Contract Documents
Sample Training Attestation Letter
Sample Debarment Attestation Letter
Sample Background Check Attestation Letter
Sample Civil Rights Compliance Plan Attestation Letter
Civil Rights Compliance Plan Letter of Assurance
Claims
Claims Appeal Submission Information
Service Contract
Attachment 1: Rates and Service Code Chart
Attachment 2: Appeals and Grievance Policy
Attachment 3: Member Use of Personal Resources
Attachment 5: Insurance Minimum Requirements
Restrictive Measures
Restrictive Measures Policy and Procedure
DHS Restrictive Measures Guidelines and Standards
Member Rights and Responsibilities
Member Rights and Responsibilities Policy and Procedure
WPS Forms and Claims Information
FAMC CLTS General Claim Submission Requirements
WPS Electronic Data Services External Access Request Form
Corrected Claim Form Tip Sheet