Get Wi Dhs F-47255 2019-2026

The WI DHS F-47255 form is essential for establishing the primary service areas for ambulance service providers in Wisconsin. This guide will provide clear, step-by-step instructions on how to accurately complete this form online, ensuring compliance with state regulations.

Follow the steps to accurately complete the WI DHS F-47255 form online.

1. Click the ‘Get Form’ button to access the WI DHS F-47255 form and open it in your online editor.
2. Begin by filling out the section titled 'Ambulance Service Provider Information.' Enter the name of the licensed service provider and their respective license number. Include the complete US postal mailing address and the Federal Employer ID Number. Make sure to have the Ambulance Service Director provide their signature and the date signed.
3. Proceed to the 'Certification of Municipality / Contracting Agency(s)' section. Each municipality included in your primary service area must certify the actual population served by your ambulance service. Enter the municipal code, the total population served, and the percentage of the total population that this number represents.
4. If there are multiple municipalities in your primary service area, you may copy the certification section as needed, ensuring each municipality has its information entered. Collect necessary signatures from the clerk of each municipality.
5. Once all information is entered and verified, scan the completed form along with any necessary attachments. Ensure all signatures are present and correct.
6. Finally, save your changes, and you may choose to download, print, or share the completed form as per your requirements. Be sure to follow up as necessary to ensure your application is processed.

Complete the WI DHS F-47255 online today to ensure your ambulance service provider is properly registered and compliant with state regulations.