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Advance Directives - Wisconsin Department of Health Services 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Ambulance Service Provider Information' section. Enter the name of your licensed service provider, license number, mailing address, and Federal Employer ID Number.
- In the same section, ensure that the Ambulance Service Director signs and dates the form to validate the information provided.
- Proceed to the 'Certification of Municipality / Contracting Agency(s)' section. Here, each municipality must certify its population served. Fill in the municipal code, total population served by your ambulance service provider, and calculate the percentage of total population represented.
- Each municipality's clerk must sign and date this section to confirm accuracy. If there are multiple municipalities, you can copy this page as needed.
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