№ lp_2_3_33068
Official state Medicaid incident reporting form documenting critical events, allegations, actions taken, notifications, and outcomes concerning participants receiving Community Recovery Services in Wisconsin.
Issuing Authority: Department of Health Services, State of Wisconsin, Division of Care and Treatment Services
Form Number: F-00390
Revision Date: 08/2016
Program: Community Recovery Services (CRS) Medicaid Benefit
Related Document: F-00390I Instructions
Jurisdiction: State of Wisconsin
Applicable Population: Children and adults receiving Community Recovery Services Medicaid benefit
Submission Method: Mail or Fax to designated CRS Contact
Reporting Timeline: Within 24 hours for Critical Incidents; three business days for agency notification to state contact
Type of Document: Official incident reporting form
Administering Agency: Wisconsin Department of Health Services
Associated Agencies: CRS County/Tribe Agency; State Medicaid Agency (SMA)
Regulatory Context: CMS-approved CRS Benefit requirements and conditions
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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