1. Long-Term Care (LTC) Providers

All Long-Term Care providers must complete and submit the following documents:

• Long-Term Care Provider Application 
• W-9 Form    
• Section III - Additional Facility Locations (This form is used to provide information for additional locations when submitting an application to iCare or for adding new services or a new location to an existing contract. Complete a separate form for each location)
• See face page within the application for additional required documents

2. 1-2 bed Adult Family Home Providers

All providers seeking a contract and/or certification of a 1-2 bed home must complete and submit the following documents:

• 1-2 bed Adult Family Home Application
• W-9 Form
• See face page within the application for additional required documents

Applicants may not reapply for certification in Wisconsin within two (2) years after the effective date under any of the following circumstances:

• Previously denied certification or licensure for cause

• A revoked certificate or license

• Voluntarily surrendered license or certification for any type of residential provider while facing active denial

• A de-certification or revocation action

If approved for contracting/certification a certification fee of $475 per facility will be required for all Corporate facilities to begin the certification process.  The annual re-certification will be $350 per facility for all Corporate facilities.