WI DHS F-47255 2019 free printable template
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DEPARTMENT OF HEALTH SERVICES Division of Public Health F47255 (Rev. 05/2019)STATE OF WISCONSIN Office of Preparedness and Emergency Health Care Wis. Stat. 256.12 6082661568EMS FUNDING ASSISTANCE
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How to fill out WI DHS F-47255
01
Begin by downloading the WI DHS F-47255 form from the official Wisconsin Department of Health Services website.
02
Fill in the applicant's personal details, including name, address, and contact information in the designated sections.
03
Provide specific information regarding the individual's health care needs and any relevant medical history.
04
Include information about the person's support network, such as family members or caregivers, who can assist with their needs.
05
Review the completed form for accuracy and completeness before submission.
06
Submit the form as instructed, either via mail or electronic submission, depending on the guidelines provided.
Who needs WI DHS F-47255?
01
The WI DHS F-47255 form is needed by individuals seeking healthcare assistance or services through the Wisconsin Department of Health Services.
02
It is also required for caregivers or family members applying on behalf of someone who needs health services.
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What is WI DHS F-47255?
WI DHS F-47255 is a form used by the Wisconsin Department of Health Services to collect information regarding various health services provided to clients.
Who is required to file WI DHS F-47255?
Providers of health services in Wisconsin who receive funding from the Department of Health Services are required to file WI DHS F-47255.
How to fill out WI DHS F-47255?
To fill out WI DHS F-47255, carefully follow the instructions provided on the form, ensuring all sections are completed with accurate and relevant information regarding services provided.
What is the purpose of WI DHS F-47255?
The purpose of WI DHS F-47255 is to gather necessary data to ensure compliance with state regulations and to evaluate the effectiveness of health service programs.
What information must be reported on WI DHS F-47255?
Information that must be reported on WI DHS F-47255 includes client demographics, types of services provided, dates of service, provider details, and any other relevant data as specified in the form instructions.
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