WI DHS F-04002 2015 free printable template
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DEPARTMENT OF HEALTH SERVICES Division of Public Health F-04002 (Rev. 08/08) STATE OF WISCONSIN s. 252.04, Wis. Stats. SCHOOL REPORT TO LOCAL HEALTH DEPARTMENT Wisconsin State Statute 252.04 requires
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How to fill out WI DHS F-04002
01
Obtain the WI DHS F-04002 form from the Wisconsin Department of Health Services website or your local office.
02
Fill in your personal information at the top of the form, including your name, address, and date of birth.
03
Provide details about your household members, including their names, ages, and relationship to you.
04
Indicate your household's income by listing all sources of income and the amounts received.
05
Answer questions regarding your expenses, such as housing, utilities, and medical costs.
06
Check the appropriate boxes to indicate any special circumstances or needs for assistance.
07
Review the form for accuracy and completeness to ensure all required information is provided.
08
Sign and date the form to certify the information is true to the best of your knowledge.
09
Submit the completed form to your local Wisconsin Department of Health Services office.
Who needs WI DHS F-04002?
01
Individuals and families seeking assistance with food benefits, healthcare coverage, or other support programs in Wisconsin.
02
Those who are applying for or renewing eligibility for public assistance programs administered by the Wisconsin Department of Health Services.
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What is WI DHS F-04002?
WI DHS F-04002 is a form used by the Wisconsin Department of Health Services to report certain data related to health service provision and Medicaid services.
Who is required to file WI DHS F-04002?
Entities providing Medicaid services in Wisconsin, including healthcare providers and facilities, are required to file WI DHS F-04002.
How to fill out WI DHS F-04002?
To fill out WI DHS F-04002, obtain the form from the Wisconsin Department of Health Services website, complete all required fields accurately, and submit it as instructed.
What is the purpose of WI DHS F-04002?
The purpose of WI DHS F-04002 is to collect necessary data for monitoring, evaluating, and improving health services within the Medicaid program in Wisconsin.
What information must be reported on WI DHS F-04002?
The information required includes provider details, service delivery data, patient demographics, and billing information related to Medicaid services.
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