Get Wi Dhs F-01744 2017-2025

The WI DHS F-01744 form is a crucial document for healthcare providers involved in the Wisconsin Immunization Program. This guide will walk you through the process of filling out the form online, ensuring that you complete each section accurately and efficiently.

Follow the steps to complete your WI DHS F-01744 form online

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate online editor.
2. Begin by entering the provider's name in the designated field, ensuring correct spelling to avoid identification issues.
3. Input the area code and phone number of the provider. This information is essential for communication regarding the vaccine restitution policy.
4. Fill in the VFC PIN number, which is necessary for participation in the Vaccines for Children Program.
5. Review the agreement statement clearly. After comprehending the policies outlined, confirm your understanding by checking the box or signing where indicated.
6. Print the name of the representative authorized to sign on behalf of the provider. Ensure this individual has the authority to make necessary commitments.
7. Sign the form in the designated signature field, ensuring the signature matches the printed name above.
8. Date the form in the space provided to confirm when the agreement was made.
9. Once all sections are filled out, save your changes, and choose to download, print, or share the completed form as needed.

Complete your document online today to ensure compliance with the Wisconsin Immunization Program.