DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62589 (Rev. 07/08) STATE OF WISCONSIN REQUEST FOR APPROVAL TO USE TELEHEALTH Completion of this form is optional. Name - Agency Certification.
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How to fill out the Dhs F 62589 Form online
This guide provides a detailed overview of how to complete the Dhs F 62589 form online. Designed for mental health and substance abuse programs, this form is essential for obtaining approval to use telehealth services.
Follow the steps to complete the form accurately.
- Press the ‘Get Form’ button to access the Dhs F 62589 form and open it for completion.
- Fill in the name of the agency and provide the certification number and date when the application is completed.
- Enter the agency's address, including street or P.O. Box, city, state, and zip code.
- Provide details about the person completing the form, including their name, telephone number, fax number, and email address.
- Indicate the name of the agency director on the specified line.
- Address the applicability section by confirming if the agency is certified or has submitted an application for certification by selecting 'Yes' or 'No' for each question.
- In the general section, ensure that the organization has outlined the requirements for telehealth services and validate each item as applicable.
- Once all required fields are completed, save your changes, download, print, or share the form as necessary.
Complete the Dhs F 62589 form online today to streamline your telehealth services approval process.
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