FCS Provider Outcome and Capacity Report

Please turn in this monthly report by the 10th of the following month. For example, submit the July report by August 10th. If you have any questions about completing this form, contact your FCS Manager or contact the FCS team at FCSTPA@wellpoint.com or 1-844-451-2828.

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Provider Information

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Contracted Service Location

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Contracted service location city

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Contracted Service Location County

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Capacity Report


Supported Employment

Number of Supported Employment full time employees (FTEs) currently working at your organization.

The maximum number of enrollees you can serve currently.

The current number of (active) enrollees your organization is serving.

The number of available enrollees you can add to your organization's case load to serve (example: maximum minus (-) current equals (=) available)

Is your organization accepting external referrals from Wellpoint for individuals wanting FCS services?

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Supportive Housing

Number of Supportive Housing full time employees (FTEs) currently working at your organization.

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Outcomes Report


Supportive Housing

Time seeking housing (of those currently seeking housing)

(Enter N/A if you don't have any enrollees)

Length of time in housing (of those currently housed)

(Enter N/A if you don't have any enrollees)

Supported Employment

Length of time seeking employment (of those currently seeking employment)

(Enter N/A if you don't have any enrollees)

Length of time employed full-time (of those currently employed)

(Enter N/A if you don't have any enrollees)

Length of time employed part-time (of those currently employed)

(Enter N/A if you don't have any enrollees)

Length of time in non-paid employment activities (of those in non-paid employment activities)

(Enter N/A if you don't have any enrollees)

Length of time in training/education activities (of those in training/education activities)

(Enter N/A if you don't have any enrollees)