The Wisconsin Medical Treatment Statement — for listing charges from medical providers, or for medicine and supplies — is a form for documenting the financial transactions that occur between a patient and a medical provider. This form is required by the Wisconsin Department of Health Services (DHS) and must be completed by the medical provider before any reimbursement can be made. The form includes the patient's name, date of service, provider name, procedure codes, and charges for services rendered. It also includes a description of the services provided, the patient’s insurance coverage, and the amount due to the provider. There are two types of Wisconsin Medical Treatment Statements: The Professional Statement and the Institutional Statement. The Professional Statement is for professional services rendered by a physician or other medical provider, and includes charges for office visits, laboratory tests, imaging, and other services. The Institutional Statement is for services rendered by a hospital or other medical facility, and includes charges for hospital stays, surgical procedures, and other services.