Legal Name (including d 2026

1. Click ‘Get Form’ to open the Legal Name application in the editor.
2. Begin by entering your Legal Name, including any 'doing business as' (d.b.a.) names in the designated field. Ensure accuracy for proper identification.
3. Fill in your Main Physical Location, including street address, city, state, and zip code. If you have additional locations, list them on page 2.
4. Complete the Main Mailing Address if it differs from your physical location. This ensures all correspondence reaches you correctly.
5. Provide your Main Phone number, Fax number, and Website URL to facilitate communication.
6. If applicable, enter your Billing/Remit Address and Billing Phone number for financial correspondence.
7. Fill out the Organizational NPI#s and Federal Tax ID#. Indicate if you are WI Medicaid Certified and list the County(s) Served.
8. Select the Type of Facility(s) you operate and indicate the Number of locations and licensed practitioners on subsequent pages as needed.

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