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

Change Request Form

Nursing Homes

Nursing Home Bed Hold Request (electronic)

Nursing Home Bed Hold Request (paper)

Current Contract Addenda

Translation Interpreter Services

Adult Day Care

Supportive Home Care

Supported Apartment Program

Home Health Care


Pre-Vocational Services

Daily Living Skills Training

Personal Electronic Monitoring and Response Services

Certified Adult Family Home

Licensed Adult Family Home

Home Delivered Meals

Nursing Home


Symptom Management

Supported Employment

Financial Management Services

Financial Management Services-SDS

Day Services

Residential Care Apartment Complex


Required Contract Documents

Sample Training Attestation Letter

Sample Debarment Policy

Sample Debarment Attestation Letter

Sample Background Check Attestation Letter

Sample Civil Rights Compliance Plan Attestation Letter

Civil Rights Compliance Plan Letter of Assurance

Provider Agreement Form


Claims Appeal Process

Claims Appeal Submission Information

Clean Claims

Service Contract

LCI Service Provider Contract

LCI Encryption User Guide

Attachment 1: Rates and Service Code Chart

Attachment 2: Appeals and Grievance Policy

Attachment 3: Member Use of Personal Resources

Attachment 4: HIPAA

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

WPS Corrected Claim Form

Corrected Claim Form Tip Sheet

Family Care Claim Submission Tips

Family Care Claim Form Outline