Residential Vacancy Form - For Providers

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Residential Vacancy

Frequently Used Forms

Residential Vacancy
Residential Summary
Provider Billing Registration

The Residential Vacancy Notification Form is used to list a vacancy or to remove a listed vacancy.

This form should only be completed by providers who are contracted with Community Care, Inc. If you have questions about whether or not you are contracted please call 866-937-2783 and select option 2 prior to submitting this form.

ATTENTION: Providers should complete the vacancy form when the vacancy is filled to notify Community Care the vacancy is no longer available. All vacancies submitted will be removed from Community Care records 60 days after the vacancy is received. Providers will be responsible to resubmit the vacancy should it exist after 60 days.

Reason for Submitting Form:

Add Vacancy
Remove Vacancy

Number of Vacant Beds:

Click to add

(?)

Provider Tax ID Number:

Click to add

(?)

Provider Contract/Corporate Name:

Click to add

(?)

Facility Name:

Click to add

(?)

Type of Facility:

Owner Occupied Adult Family Home
Certified Adult Family Home
Licensed Adult Family Home
CBRF
RCAC

Facility Address:

Click to add

(?)

Facility Address Line 2:

Click to add

(?)

Facility City:

Click to add

(?)

Facility State:

Click to add

(?)

Facility Zip:

Click to add

(?)

Contact Name for Vacancy:

Click to add

(?)

Contact Phone for Vacancy:

Click to add

(?)

Contact Email Address for Vacancy:

Click to add

(?)

Vacancy is for Gender:

Male
Female
Either

Available Room Is:

Private
Shared

Room Location is on the:

1st Floor
2nd Floor
3rd Floor
4th Floor
Lower Level

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PLEASE NOTE: Upon pressing the submit button, you should see a message stating that we have received your information. If you do not, please scroll up, complete any of the required fields noted in red, then submit the form again.

Community Care only lists vacancies for contracted providers who have submitted Residential Summaries. The vacancy list is always available for Community Care’s care managers to review. We ask that you use the online form above to report your vacancies and not call the care managers/sites directly to discuss or announce your vacancies. We cannot guarantee referrals since we are unable to determine how many members will be seeking placements at any given time.

Corporate Headquarters: 205 Bishops Way, Brookfield, WI 53005
Phone: (414) 231-4000 | Toll Free: 1-866-992-6600 | TTY: Call the Wisconsin Relay System at 711
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