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DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80130 08/2011 STATE OF WISCONSIN FINANCIAL INFORMATION Providing the information requested on this form meets the provisions of DHS 1. Interviewed by Date Interviewed Annual or Periodic Review Name Reviewer I also understand these statements may be verified. SIGNATURE Applicant Action No Change Change Notes Updated F-80130 Prepared. Employer Name and City TOTAL MONTHLY INCOME Find...

How to fill out dmt 130 form

How to fill out dhs wi dmt 130:

1. Start by entering your personal information such as name, address, and contact details in the appropriate fields.
2. Provide the necessary information regarding your current employment status, including employer details and job title.
3. Indicate your household composition by listing the names and relationship of all individuals living with you.
4. Specify your income and financial resources by filling out the relevant sections, including details about wages, self-employment, public assistance, and other sources of income.
5. Provide information about your expenses, including rent/mortgage, utilities, medical expenses, childcare costs, and more.
6. Complete the sections related to medical insurance coverage and any disabled or incapacitated individuals in your household.
7. Sign and date the form to validate your information and certify that it is accurate to the best of your knowledge.

Who needs dhs wi dmt 130:

1. Individuals who are seeking assistance with their healthcare or need to apply for Medicaid in Wisconsin.
2. Those who are experiencing financial hardship and need to determine their eligibility for various healthcare programs.
3. People who require assistance in covering the costs of medical expenses, including doctor visits, prescriptions, and hospital stays.

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What is dhs wi dmt 130?

DHS WI DMT 130 is a form used by the Wisconsin Department of Health Services for reporting certain financial and demographic information related to the provision of health services.

Who is required to file dhs wi dmt 130?

Providers of health services in Wisconsin who receive funding or support from the Department of Health Services are typically required to file DHS WI DMT 130.

How to fill out dhs wi dmt 130?

To fill out DHS WI DMT 130, follow the instructions on the form, providing required information regarding services provided, funding received, and relevant demographic data.

What is the purpose of dhs wi dmt 130?

The purpose of DHS WI DMT 130 is to collect standardized information from health service providers to ensure compliance with funding requirements and assess service delivery.

What information must be reported on dhs wi dmt 130?

Information required on DHS WI DMT 130 includes service delivery details, financial data, provider demographics, and statistics relevant to the operations of health services.