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)
Residential
Residential Provider Attachments
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
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
WPS Forms and Claims Information
FAMC CLTS General Claim Submission Requirements
WPS Electronic Data Services External Access Request Form
Corrected Claim Form Tip Sheet