Fiscal Agent Forms

This page contains a listing of Fiscal Agent related Forms.

Change: Name, Address, Phone

  1. Member-Employer Name Change
  2. Employee Notification of Name Change
  3. Notification of Address - Phone Change

Complete Employer and Employee Packet

  1. Employer/Member Enrollment Packet
  2. Employee Packet
  3. Care Wisconsin Employee Packet
  4. Winnebago ADRC Employee Packet
  5. Winnebago Waiver Employee Packet
  6. Fiscal Conduit for Purchases and Services
  7. Fiscal Conduit for Mileage

Employer/Member Handbook

  1. Fiscal Agent Employer/Member Handbook

Employment Postings

  1. Employer Posting Packet

Fraud and Abuse

  1. Reporting Fraud & Abuse (State of Wisconsin)
  2. Medicare Fraud & Abuse: Prevention, Detection, and Reporting (US)

Payroll Forms

  1. 2019 Time Report and Pay Schedule
  2. 2018 Payroll Schedule
  3. Time Report (Time Sheet)
  4. Sample Time Report (Time Sheet)
  5. Mileage Log
  6. Sample Mileage Log
  7. Participant Check Request
  8. Direct Deposit Form
  9. W-4 form (Federal)
  10. W4 Example - If you qualify to claim exempt status
  11. WT-4 form (Wisconsin)
  12. WT4 Example - If you qualify to claim exempt status

Other Forms

  1. Employee Reciprocity Declaration
  2. Care WI Training
  3. Supportive Home Care Training
  4. Medicaid Program Provider Agreement Form
  5. Medicaid Program Provider Agreement Form - Spanish Version
  6. 2678 Employer Appointment of Agent
  7. Background Information Disclosure (BID)
  8. Mileage Provider Information


  1. Form I-9, Employment Eligibility Verification
  2. How to complete an I-9
  3. W4 Worksheet and Information
  4. W9 with instructions
  5. Consumer Web Entry Guide
  6. Employee Web Entry Guide
  7. Medicaid Program Provider Letter from State of Wisconsin

Payroll Information

  1. Timesheet Reminders - Insert
  2. Vendor/Fiscal Conduit Reminders - Insert