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How to use or fill out Legal Name (including d) with our platform
- Click ‘Get Form’ to open the Legal Name application in the editor.
- Begin by entering your Legal Name, including any 'doing business as' (d.b.a.) names in the designated field. Ensure accuracy for proper identification.
- Fill in your Main Physical Location, including street address, city, state, and zip code. If you have additional locations, list them on page 2.
- Complete the Main Mailing Address if it differs from your physical location. This ensures all correspondence reaches you correctly.
- Provide your Main Phone number, Fax number, and Website URL to facilitate communication.
- If applicable, enter your Billing/Remit Address and Billing Phone number for financial correspondence.
- Fill out the Organizational NPI#s and Federal Tax ID#. Indicate if you are WI Medicaid Certified and list the County(s) Served.
- 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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