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Wisconsin Department of Health Services Forms

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Wisconsin Last Will and Testament Form

LAST WILL AND TESTAMENT OF

I, , of County, Wisconsin, being of legal age and of sound and disposing mind and memory, and not acting under duress, menace, fraud, or undue influence of any person, do make, declare and publish this to be my Will and hereby revoke any Will or Codicil I may have made.

ARTICLE ONE

Marriage and Children

I am married to and have the following children from our marriage:

Name: Date of Birth:

Name: Date of Birth:

Name: Date of Birth:

Name: Date of Birth:

My spouse was previously married and has the following children from a prior marriage:

Name: Date of Birth:

Name: Date of Birth:

Name: Date of Birth:

Name: Date of Birth:

I was previously married and have the following children from that marriage:

Name: Date of Birth:

Name: Date of Birth:

Name: Date of Birth:

Name: Date of Birth:

ARTICLE TWO

Debts and Expenses

I direct my Personal Representative to pay all costs and expenses of my last illness and funeral expenses. I further direct my Personal Representative to pay all of my just debts that may be probated, registered and allowed against my estate.

ARTICLE THREE

Specific Bequests of Real and/or Personal Property

I will, give and bequeath unto the persons named below, if he or she survives me, the property described below:

Name/Address/Relationship

Property Description

ARTICLE FOUR

Homestead or Primary Residence

I will, devise and bequeath all my interest in my homestead or primary residence to my spouse if he or she survives me. Sign if selected:

OR

I will, devise and bequeath all my interest in my homestead or primary residence to:

and equally, per stirpes. Sign if selected:

ARTICLE FIVE

All Remaining Property – Residuary Clause

I give all the rest and remainder of my property and estate to the following beneficiaries, equally, per stirpes:

and equally, per stirpes. Sign if selected:

My spouse named . Sign if selected:

ARTICLE SIX

Contingent - All Remaining Property – Residuary Clause

Not applicable because I selected option 1 in Article Five above.

If my spouse predeceases me, I give the rest and remainder of my property to:

and equally, per stirpes. Sign if selected:

ARTICLE SEVEN

Property To Vest In Trustee for Child Beneficiary

If my spouse predeceases me and any beneficiary is under the age of years, then I direct that my trustee shall hold such share in trust.

When each beneficiary reaches age years, and when the youngest beneficiary reaches age years, the trust shall terminate.

If any beneficiary dies before final distribution, the trustee shall distribute according to the trust terms. If my youngest beneficiary is over years of age, the trust shall be inoperative.

ARTICLE NINE

Appointment of Trustee

I appoint , or if the appointee fails to qualify or cease to act, I appoint as Trustee.

ARTICLE TEN

Appointment of Guardian

In the event that a guardian is necessary for any of my children under the age of years, I appoint as Guardian.

ARTICLE ELEVEN

Appointment of Personal Representative, Executor or Executrix

I hereby appoint as Personal Representative. Successor Personal Representative:

ARTICLE TWELVE

Waiver of Bond, Inventory, Accounting, Reporting and Approval

My Personal Representative and successor Personal Representative shall serve without bond, and I waive inventory, accounting, appraisal, reporting, approvals, or final appraisement.

ARTICLE THIRTEEN

Powers of Personal Representative, Executor and Executrix

I grant broad powers to my Personal Representative as set forth in the will text.

ARTICLE FOURTEEN

Construction Intentions

If my spouse, , and I die under circumstances where it is difficult to determine who died first, I direct that I be deemed to have survived her/him.

ARTICLE FIFTEEN

Misc. Provisions

If any person named herein is indebted to me at the time of my death, such person's portion of my estate shall be diminished by the amount of such debt.

Any and all debts of my estate shall first be paid from my residuary estate.

I desire to be buried in the cemetery in County, .

I direct that my remains be cremated and that the ashes be disposed of according to the wishes of my Executor.

I, , having signed this Will in the presence of and who attested it at my request on this the day of , 20, at (address), declare this to be my Last Will and Testament.

Testator/Testatrix

Witness Signature

Print Name:

Address:

Telephone No.

Print Name:

Address:

Telephone No.

Wisconsin Self-Proving Affidavit

I, , the Testator/Testatrix, sign my name to this above and foregoing instrument this day of , 20, and being first duly sworn, declare to the undersigned authority all of the following:

1. I execute this instrument as my Will.

2. I sign this will willingly.

3. I execute this will as my free and voluntary act for the purposes expressed therein.

4. I am 18 years of age or older, of sound mind, and under no constraint or undue influence.

Testator/Testatrix

Typed Name

We, and , the witnesses, being first duly sworn sign our names to this instrument, and do hereby declare to the undersigned authority all of the following:

1. The testator/testatrix signs and executes this instrument as his or her will.

2. The testator/testatrix signs it willingly.

3. Each of us, in the conscious presence of the testator/testatrix signs this will as witness.

4. To the best of our knowledge the testator/testatrix is 18 years of age or older, of sound mind, and under no constraint or undue influence.

Witness

Witness

State of Wisconsin

County of

Subscribed, sworn to and acknowledged before me by , the testator/testatrix and subscribed and sworn to before me by and , witnesses, this day of , 20.

NOTARY PUBLIC

My Commission Expires:

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What the Wisconsin Department of Health Services Forms are and who they serve

Wisconsin Department of Health Services Forms are official state forms used to request services, report health information, enroll providers, apply for benefits, or document consent within Wisconsin's public health and human services programs. They include program-specific applications, provider enrollment packets, consent and release forms, incident reports, and eligibility questionnaires. Many forms are used by individuals, healthcare providers, employers, and local agencies to support Medicaid, BadgerCare, clinical reporting, and licensing workflows. The forms may be filed electronically or on paper depending on the program and signature requirements.

Why accurate completion matters for service access and compliance

Correctly completed Wisconsin DHS forms speed determinations, reduce request rework, and ensure legal compliance for privacy and benefits. Accurate submissions help avoid eligibility delays, claim denials, or reporting gaps while preserving audit trails required for program integrity and oversight.

Why accurate completion matters for service access and compliance

Who commonly prepares and signs these DHS forms

Several distinct groups prepare and sign Wisconsin DHS forms depending on the program and purpose.

  • Individuals and applicants completing benefit or enrollment requests for Medicaid, BadgerCare, or long‑term care services
  • Healthcare providers submitting provider enrollment forms, claims attachments, or clinical reports
  • Employers and program administrators reporting workplace incidents or employee health benefits
  • Legal representatives, guardians, or authorized agents completing consent or power‑of‑attorney attachments

Roles and responsibilities vary with the form; check the specific form instructions for who must sign, whether a witness or notary is required, and whether electronic signatures are accepted.

Authorized signers and typical submitters

Applicant

An individual applying for benefits or services who must sign attestations and authorizations. If the applicant is a minor or incapacitated, a parent, guardian, or legally authorized representative signs on their behalf with supporting documentation.

Provider Representative

A licensed provider or designated office manager who enrolls a practice, certifies service delivery, or reports clinical data. Their signature must match licensed provider records and may require NPI or provider number verification.

Common required data fields found on DHS forms

Full legal name: Exact name on ID
Date of birth: MM/DD/YYYY
Address: Street, city, state, ZIP
Recipient identifier: Medicaid/ID number
Provider number: NPI or state provider ID
Signature and date: Signed and dated

Step-by-step: filling out a typical DHS form

Follow these sequential steps for a complete and valid submission to Wisconsin DHS.

  • 01
    Gather documents: Collect IDs, proof of address, and supporting records
  • 02
    Complete fields: Enter data exactly, use MM/DD/YYYY for dates
  • 03
    Review signatures: Confirm authorized signer and add date
  • 04
    Submit correctly: File via accepted channel with attachments

How to set up an electronic workflow for DHS form completion

Configure a digital workflow to collect required fields, attachments, and signatures while preserving an audit trail.

Field Configuration
Required Fields Mark name, DOB, program ID as required
Attachments Permit PDF, JPG; set size limits
Signature Type Allow electronic signature or image upload
Authentication Enable email or SMS code verification

Where to send or file Wisconsin DHS forms

Destination and routing depend on the specific program; confirm the correct office or electronic portal before submission.

  • Online portal: Upload via the program’s DHS web portal when available
  • Mail: Send physical forms to the address on form instructions
  • Email: Only permitted where form guidance allows electronic attachments
  • In person: Deliver to local county human services or DHS office if required

Digital signing and eSubmission basics for DHS forms

Verify whether a specific Wisconsin DHS form accepts electronic signatures and which authentication methods are required.

  • Accepted formats: PDF and scanned images
  • Authentication: Email link or SMS code
  • Audit trail: Capture IP, timestamp, and signer info

When in doubt, follow the form’s instruction page. For health information, ensure eSubmission meets HIPAA requirements and that a Business Associate Agreement is in place when using third‑party tools.

Typical deadlines and processing expectations

Timing varies by program; some forms are time‑sensitive for benefit eligibility, reporting, or tax reporting obligations.

Benefit applications:

Process times vary; submit ASAP to avoid service gaps

Provider enrollment:

Expect several weeks for approval

Clinical reporting:

Follow program schedule or statutory timelines

Tax and information returns:

See IRS deadlines like Jan 31 for 1099‑NEC

Retention obligations:

Keep records per agency retention rules

Key processing milestones for a completed submission

Watch these sequential milestones from submission through final disposition.

01

Submission Received

Agency logs receipt and issues tracking number

02

Initial Review

Clerical checks for completeness and attachments

03

Substantive Evaluation

Program staff assess eligibility or compliance

04

Final Determination

Approval, denial, or request for more information

Essential components to include on professional DHS form submissions

Ensure each completed form contains these core elements to improve acceptance rates and simplify audits.

Complete identifiers

Include full legal name, date of birth, and program or provider numbers to enable exact record matching and reduce manual reconciliation.

Clear signature

A dated signature block with the printed name and relationship to the applicant verifies authorization and supports legal enforceability.

Accurate dates

Use MM/DD/YYYY for all dates; effective and signature dates determine eligibility windows and statutory deadlines for appeals.

Supporting evidence

Attach required documents such as ID, proof of residency, or clinical records; label attachments and ensure legibility to avoid return requests.

Contact details

Provide phone, email, and mailing address so DHS staff can request clarification and deliver determinations without delay.

Privacy consent

Include signed authorizations for release of protected health information where required to comply with HIPAA for clinical data sharing.

Common mistakes that cause rejections or delays

  • Missing or mismatched names between form and supporting ID leading to identity verification failures and file returns
  • Incomplete fields or unchecked mandatory boxes that trigger administrative returns and extend processing time
  • Poor quality scans or incorrect file formats for attachments resulting in unreadable evidence and resubmission requests
  • Using unsupported electronic signature methods where the specific form requires notarization or specific authentication

Consequences of incorrect or late filings

Benefit delays: Service interruption or delayed eligibility
Denial risk: Incomplete or incorrect forms may cause denial
Penalties: Statutory fines may apply in regulated contexts
Audit exposure: Insufficient records increase audit risk
Privacy violations: Improper handling of PHI may breach HIPAA
Tax consequences: Incorrect reporting can trigger IRS penalties

Real-world examples of DHS form workflows

These concise case scenarios show how organizations manage DHS forms and signatures in practice.

Provider Enrollment

A clinic completes a provider enrollment packet online

  • Uses NPI and tax ID for verification
  • The clinic received approval after submitting complete attachments and a dated signature, reducing manual follow up and shortening onboarding by several weeks.

Benefit Application

An applicant files a benefits application with scanned ID

  • Includes proof of residency and income
  • The agency processed the application faster because fields matched verification records and the submission included required attachments, avoiding a duplicate request for documents.

Practical tips to speed acceptance and reduce errors

Follow these practices to cut processing time and administrative back‑and‑forth on DHS forms.

Validate identity early
Confirm legal names and identifiers before completing forms so verification steps do not delay final determination.
Use clear scans
Provide legible, high‑contrast PDF attachments and avoid mobile blur to prevent document rejection.
Follow form instructions
Adhere strictly to the form’s signer, witness, and notary requirements to avoid invalidation.
Maintain audit logs
Retain submission receipts, emails, and signed copies to support appeals and audits.

Electronic signature types versus digital signatures — key differences

Understanding the technical and legal distinctions helps choose the right signing method for DHS submissions and protected records.

Criteria Electronic Signature Digital Signature
Definition broad electronic process cryptographic pki certificate
Legal status accepted under esign/ueta accepted and stronger evidence
Non‑repudiation audit trail based cryptographic certificate provides non‑repudiation
Use case routine forms and consents high‑assurance or regulatory records

Representative eSignature vendor pricing and capability comparison

Below is a concise comparison of starting prices and core capabilities among common eSignature vendors; signNow is listed first per platform data.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Trial available Trial available
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about Wisconsin DHS forms

Answers to common questions about signatures, notarization, and electronic submission for Wisconsin Department of Health Services Forms.


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