NS: This notification form is not required for health care providers providing services to patients located in Wisconsin only via telehealth. Each health care provider listed on this form MUST submit an Act 10 online application via LicensE, https://license.wi.gov/. (See information sheet #2021-A101 for details.) Health care employer, for purposes of this form, means a system, care clinic, care provider, long-term care facility, or any entity whose employed, contracted, or affiliated staff provi.
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How to fill out the WI Form 2021-A102 online
Filling out the WI Form 2021-A102 is an essential step for health care employers seeking to notify the Wisconsin Department of Safety and Professional Services about health care providers. This guide will help you complete the form online with clear, step-by-step instructions.
Follow the steps to fill out the WI Form 2021-A102 accurately.
- Press the ‘Get Form’ button to obtain the form and open it in your browser.
- In the section for 'Name of Health Care Employer', enter the full legal name of your organization providing health care services.
- Provide the complete address of the health care employer, ensuring you fill in the 'Number/Street', 'City', 'State', and 'Zip Code' fields accurately.
- If the address listed is out of state, include the name and address of the Wisconsin facility or system where the health care provider will be rendering services.
- In the health care provider section, fill in their 'Last Name', 'First Name', and 'Middle Name' as necessary.
- Enter the 'LicensE Preliminary Application Reference (PAR)'. This number is crucial for your submission.
- Select the 'State Where Licensed' and provide the corresponding license number for the health care provider.
- Indicate the 'Start Date for This Provider at the Facility' using the mm/dd/yyyy format.
- Read each attestation carefully, and by signing below, confirm that you have adhered to the declarations outlined.
- Complete the signature field, write the date in mm/dd/yyyy format, enter the printed name, phone number, and title of the individual completing the form.
- Once the form is filled out, save your changes. You can download, print, or share the form as needed.
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