Outdated or Unsupported Browser Detected
DWD's website uses the latest technology. This makes our site faster and easier to use across all devices. Unfortunatley, your browser is out of date and is not supported. An update is not required, but it is strongly recommended to improve your browsing experience. To update Internet Explorer to Microsoft Edge visit their website.
Document Number: DVR-18045-E
Description: This form is to be completed by DVR Service Providers to report on benefits consultation period services authorized by DVR.
Comments: Form is protected from modification and enabled for form fill (includes tabbed fields for form completion).
Content Contact: DVR Forms
Document Attachments:
DVR-18045-E (Electronic Version - Word/66 KB)
DVR-18045-E (Electronic Version - pdf/86 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
Sign up for DWD news and updates
A proud partner of the 
network