Get Wi Form 2021-a102 2021-2025

Filling out the WI Form 2021-A102 is a crucial process for health care employers notifying the Wisconsin Department of Safety and Professional Services about licensed health care providers. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form online:

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the name of the health care employer in the designated field.
3. Next, input the complete address of the health care employer, including street, city, state, and zip code.
4. Provide the health care provider information. Include the last name, first name, and middle initial in the respective fields.
5. Indicate the profession of the health care provider, noting the specialty if applicable.
6. List the other state where the health care provider is currently licensed, along with the respective license number.
7. Fill in the start date at the facility using the specified mm/dd/yyyy format.
8. If you have multiple providers, attach additional sheets in the same format as before and ensure all information is complete.
9. Complete the attestation section by confirming the validity of each provider's credential and that they are not under investigation.
10. Print and sign the form, including your printed name, title, and the date.
11. Finally, save your changes, and prepare to submit the completed form to the designated email address.

Complete the WI Form 2021-A102 online today to ensure timely processing.