Seal of Dane County County of Dane
Dane County Department of Human Services Provider Hub

Client Registration Form

The Department has a distributed service delivery program, in that there are a number of autonomous Purchase of Service providers, and there is no centralized intake system. Providers determine the clients they will serve and register their own clients. As part of that process, they must ensure the client is known to the Department, and they must get the Client Number from the Department to use in registration and subsequent monthly reporting.

There are two forms that can be used for requesting a client number.

Client Number Request Form

The Client Number Request form must be used for all clients new to your program. Multiple clients can be listed on this form.

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Client Registration Form (600 Form)

The Client Registration form (a.k.a. “600” form) must be used if the client is new to your program. This should be submitted with your client number request form. Only one client can be listed on the form.

The provider must complete the form for each client at the time the client is first served. The form must be submitted to the Department as the clients are encountered, or at least in time to get the client number(s) in so that the provider can complete the monthly client service reporting by the 10th of the following month.

The forms should be faxed to the provider's designated data entry contact at (608) 242-6288, and they will fax the form back to the provider with the client number(s) on it.

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