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Recipient created tax invoice rcti agreement

Advance Directives - Wisconsin Department of Health Services 2026

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The document outlines the requirements for establishing the primary service area for ambulance service providers in Wisconsin, as mandated by state law. It includes instructions for obtaining municipal population verifications necessary for EMS funding assistance applications. The form requires information from the ambulance service provider and certifications from municipalities regarding the population served and its percentage representation. Signatures from both the ambulance service director and municipal clerks are required to validate the information.

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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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