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County Waiver Agency (CWA) Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Program CWA Provider Registry Gateway, F-02341 (11/2019)

County Waiver Agency's CLTS Waiver Provider Contact (F-02341)

The CLTS Waiver Program County Waiver Agency (CWA) Provider Registry Gateway includes provider data and CLTS Medicaid Waiver Provider Agreement forms needed for provider authorization.
The Wisconsin Department of Health Services (DHS) will use information provided in this form to determine access for your county waiver agency (CWA) to the Gateway.

If approved, you will be granted access to the CLTS Waiver Program CWA Provider Registry Gateway. DHS will share information related to CLTS waiver provider registration with you on this site.

Each CWA must have at least two agency contacts: a primary and a back-up. Staff who, as a part of their work, screen and determine qualified providers, authorize services, or manage quality assurance audits and reviews will be granted access.

If you no longer require access to this information due to changes in your job duties or employment, please notify the DHS Provider Registry immediately by completing this form.