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Forms: A to E

This alphabetical list contains forms that are available from this site. A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms. Microsoft Word - Fillable or Excel forms, can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Key word explanations for Form Type and Other Location columns.

Division Prefix / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
HCF-01161 F-01161 Abortion Certification Statements Word None English
HCF-01161 F-01161 Abortion Certification Statements (PDF, 94 KB) PDF None English
DPH-00117 F-40117 Abortion Information Provision Certification (PDF, 179 KB) PDF None English
DPH-00117A F-40117S Abortion Information Provision Certification - Spanish (PDF, 243 KB) PDF Form Center Spanish
DQA F-00891 Abuse and Neglect Prevention Training - DVD Request (PDF, 20 KB) PDF None English
DLTC F-01213 Accessibility Assessment Request Word None English
DMT-0460 F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2 Excel None English
DPH F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification (PDF, 17 KB) PDF None English
DPH-05023 F-05023 Acknowledgement of Marital Child Restricted Program English
HCF-01160 F-01160 Acknowledgement of Receipt of Hysterectomy Information Word None English
HCF-01160 F-01160 Acknowledgement of Receipt of Hysterectomy Information (PDF, 131 KB) PDF None English
DHCAA F-01160H Acknowledgement of Receipt of Hysterectomy Information - Hmong Word None Hmong
DHCAA F-01160H Acknowledgement of Receipt of Hysterectomy Information - Hmong (PDF, 57 KB) PDF None Hmong
DHCAA F-01160S Acknowledgement of Receipt of Hysterectomy Information - Spanish Word None Spanish
DHCAA F-01160S Acknowledgement of Receipt of Hysterectomy Information - Spanish (PDF, 42 KB) PDF None Spanish
DHCAA F-01160AH Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (Hmong) (PDF, 23 KB) PDF None English
DHCAA F-01160AS Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-01160A Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF, 23 KB) PDF None English
DPH-04151 F-44151 Acute and Communicable Disease Case Report Word Form Center English
DPH-04151 F-44151 Acute and Communicable Disease Case Report (PDF, 149 KB) PDF Form Center English
DHCAA F-00916 ADAP WCDP and WWWP Provider File Update Request Word None English
DHCAA F-00916 ADAP WCDP and WWWP Provider File Update Request (1444 KB) PDF None English
DHCAA F-00916A ADAP WCDP and WWWP Provider File Update Request Completion Instructions (28 KB) PDF None English
DPH-07208A F-47208A Additional Page for Recreational Sanitation Paper Form Center English
HCF-16038 F-16038 Administrative Disqualification Hearing Notice (PDF, 101 KB) PDF None English
DDE-5213 F-25213 Admission to Caseload - Mental Health Word None English
DDE-5213 F-25213 Admission to Caseload - Mental Health (PDF, 14 KB) PDF None English
DDE-5904 F-25904 Admission to Caseload - Revocation Word None English
DDE-5904 F-25904 Admission to Caseload - Revocation (PDF, 85 KB) PDF None English
DLTC F-01322 ADRC Activity Reporting Template-Model Excel None English
DLTC F-00037G ADRC Quality Improvement Listserv HTML None English
OQA-2603 F-62603 Adult Day Care and Family Adult Day Care Background Character Verification Word None English
OQA-2603 F-62603 Adult Day Care and Family Adult Day Care Background Character Verification (PDF, 61 KB) PDF None English
OQA-0947 F-60947 Adult Day Care Certification Standards Checklist Word None English
OQA-0947 F-60947 Adult Day Care Certification Standards Checklist (PDF, 59 KB) PDF None English
OQA-2418 F-62418 Adult Day Care Initial Certification Application Word None English
OQA-2418 F-62418 Adult Day Care Initial Certification Application (PDF, 58 KB) PDF None English
DDE-0439 F-20439 Adult Family Home (AFH) Renewal of Certification - Grandfathering Request Word None English
DDE-0439 F-20439 Adult Family Home (AFH) Renewal of Certification - Grandfathering Request (PDF, 45 KB) PDF None English
OQA-0953 F-60953 Adult Family Home Fire Safety Guide Word None English
OQA-0953 F-60953 Adult Family Home Fire Safety Guide (PDF, 25 KB) PDF None English
OQA-0945 F-60945 Adult Family Home Initial License Application Word None English
OQA-0945 F-60945 Adult Family Home Initial License Application (PDF, 77 KB) PDF None English
OQA-2671 F-62671 Adult Family Home Initial Licensure Checklist Word None English
OQA-2671 F-62671 Adult Family Home Initial Licensure Checklist (PDF, 16 KB) PDF None English
DPH-00310 F-40310 Adult Oral Health Screening (PDF, 176 KB) PDF None English
DLTC F-21150A Adult Protective Services (APS) Investigation Transfer-Model Word None English
DDE-0441A F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection (PDF, 21 KB) PDF None English
DDE-0441AI F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values (PDF, 24 KB) PDF None English
DPH F-00893 Affidavit of No Social Security Number - EMS Professional Licensing Word None English
HCF-9002 F-19002 Affidavit of Return or Exchange of Food Coupons (PDF, 615 KB) PDF None English
DPH-40019 F-40019 Affirmation of Identity, Residency, and/or Income (PDF, 35 KB) PDF None English
DPH-40019S F-40019S Affirmation of Identity, Residency, and/or Income - Spanish (PDF, 18 KB) PDF None Spanish
DPH-04021 F-04021 Age Grade Level Requirements Paper Program English
DPH-04021S F-04021S Age Grade Level Requirements - Spanish Paper Program Spanish
DDE-0418 F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool Word None English
DDE-0418 F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool (PDF, 52 KB) PDF None English
DHCAA F-00639 Agency Data Security Staff User Agreement Word None English
HCF-10145 F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding (PDF, 25 KB) PDF None English
HCF-10171 F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) PDF None English
HCF-16050 F-16050 Agency Response to the State Quality Assurance (QA) FoodShare (FS) Finding (PDF, 183 KB) PDF None English
HCF-10172 F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) PDF None English
DPH-07219 F-47219 Agent Change Sheet Paper Program English
DLTC F-00052A Aging and Disability Resource Center (ADRC) Annual Budget Excel None English
DLTC F-00052 Aging and Disability Resource Center (ADRC) Application Word None English
DLTC F-01267 Aging and Disability Resource Center (ADRC) Complaint Report Word None English
DPH-04614IS F-44614IS AIDS / HIV Health Insurance and Drug Program Application Instructions - Spanish (PDF, 38 KB) PDF None Spanish
DPH-04614I F-44614I AIDS / HIV Health Insurance Premium Subsidy Program and AIDS / HIV Drug Assistance Program - Application Instructions (PDF, 38 KB) PDF None English
DPH-04614AB F-44614A AIDS / HIV Health Insurance Premium Subsidy Program and AIDS / HIV Drug Assistance Program - Initial Application Part A - Applicant (PDF, 2418 KB) PDF None English
DPH F-00851 AIDS/HIV Drug Assistance and Insurance Premium Subsidy Programs - Six Month Report (PDF, 105 KB) Word None English
DPH-04614AB F-44614B AIDS/HIV Drug Assistance Program Application - Part B Physician Portion PDF None English
DPH-04614ABS F-44614BS AIDS/HIV Drug Assistance Program Application - Part B Physician Portion PDF None Spanish
DPH F-00601 Algal Bloom Exposure Report System None English
OQA-2617 F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report System None English
DLTC F-21343E Alzheimer's Family and Caregiver Support Program - General Information Word None English
DLTC F-21343I Alzheimer's Family and Caregiver Support Program - Instructions (PDF, 41 KB) PDF None English
DLTC F-21343D Alzheimer's Family and Caregiver Support Program Actual County Service Payment - Worksheet 4 Word None English
DDE-0906 F-20906 Alzheimer's Family and Caregiver Support Program Annual Fiscal Report* System None English
DDE-1343 F-21343 Alzheimer's Family and Caregiver Support Program Budget Report System None English
DLTC F-21343C Alzheimer's Family and Caregiver Support Program Cost-Share Calculation - Worksheet 3 Word None English
DLTC F-21343B Alzheimer's Family and Caregiver Support Program Financial Eligibility Determination - Worksheet 2 Word None English
DLTC F-21343A Alzheimer's Family and Caregiver Support Program Financial Eligibility Screen - Worksheet 1 Word None English
DPH-07247 F-47247 Ambulance Attendant License/Permit Renew System None English
DPH-07300 F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments (PDF, 55 KB) PDF Program English
DPH-07119 F-47119 Ambulance Run Report (PDF, 110 KB) PDF Program English
HCF-01070 F-01070 Ambulance Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01072 F-01072 Ambulatory Surgical Center Terms of Reimbursement (PDF, 42 KB) PDF None English
OQA-2502 F-62502 Analyst Application to Perform Alcohol Tests Word None English
OQA-2502 F-62502 Analyst Application to Perform Alcohol Tests (PDF, 57 KB) PDF None English
HCF-01074 F-01074 Anesthetist Terms of Reimbursement (PDF, 42 KB) PDF None English
DPH-40074 F-40074 Annual Physical Activity Record (PDF, 27 KB) PDF None English
DPH F-40093 Annual ROSIE User Security and Confidentiality Agreement Word None English
DPH-40093 F-40093 Annual ROSIE User Security and Confidentiality Agreement (PDF, 132 KB) PDF None English
DQA F-00913 Annual Survey of Nursing Homes - 2013 Word None English
DPH-04126 F-44126 Antituberculosis Therapy Program Medication Refill Request (PDF, 40 KB) PDF None English
DPH-04125 F-44125 Antituberculosis Therapy Program - Follow-up on Therapy (PDF, 47 KB) PDF None English
DQA F-00417 AODA Prevention Services Recertification Application - DHS 75.04 Word None English
DQA F-00417 AODA Prevention Services Recertification Application - DHS 75.04 (PDF, 52 KB) PDF None English
DLTC F-00237 Appeal Request - MCOs Word None English
DPH-43005 F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications (PDF, 897 KB) PDF None English
DPH-45013 F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography Word None English
DPH-45013 F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography (PDF, 52 KB) PDF None English
DPH-45012 F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy Word None English
DPH-45012 F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy (PDF, 64 KB) PDF None English
DPH-45016 F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope Word None English
DPH-45016 F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope (PDF, 47 KB) PDF None English
OQA-2503 F-62503 Application for Blood / Urine Alcohol Analysis Procedure Approval Word None English
OQA-2503 F-62503 Application for Blood / Urine Alcohol Analysis Procedure Approval (PDF, 66 KB) PDF None English
DPH-07346 F-47346 Application for Certified Food Manager (PDF, 11 KB) PDF None English
OQA-2461 F-62461 Application For Critical Access Hospital Certification Of Approval Paper Program English
DDE-0582 F-20582 Application for Katie Beckett Program Wisconsin Medicaid Word None English
DDE-0582I F-20582i Application for Katie Beckett Program Wisconsin Medicaid, Instructions (PDF, 23KB) PDF None English
DDE-0582IH F-20582iH Application for Katie Beckett Program Wisconsin Medicaid, Instructions - Hmong (PDF, 33 KB) PDF None Hmong
DDE-0582IS F-20582iS Application for Katie Beckett Program Wisconsin Medicaid, Instructions - Spanish (PDF, 36 KB) PDF None Spanish
DPH-45022 F-45022 Application for Material License Word None English
DPH-45022 F-45022 Application for Material License (PDF, 15 KB) PDF None English
DPH-45017 F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources Word None English
DPH-45017 F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources (PDF, 127 KB) PDF None English
DPH-45009 F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices Word None English
DPH-45009 F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices (PDF, 40 KB) PDF None English
DPH-45006 F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gages or XRF Devices (PDF, 44 KB) PDF None English
DPH-45006 F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices Word None English
DPH-45014 F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators Word None English
DPH-45014 F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators (PDF, 29 KB) PDF None English
DPH-45015 F-45015 Application for Radioactive Material License for Broad Scope Word None English
DPH-45015 F-45015 Application for Radioactive Material License for Broad Scope (PDF, 33 KB) PDF None English
DPH-45008 F-45008 Application for Radioactive Material License for Medical Use Word None English
DPH-45008 F-45008 Application for Radioactive Material License for Medical Use (PDF, 132 KB) PDF None English
DPH-07460 F-47460 Application for Recertification of Food Manager (PDF, 15 KB) PDF None English
DPH-07097 F-47097 Application for Registration of Ionizing Radiation Sources (PDF, 29 KB) PDF None English
DPH-44011 F-44011 Application for Registration of Lead-Free or Lead-Safe Property (PDF, 52 KB) PDF None English
DPH-07337 F-47337 Application for Registration of Tanning Devices (PDF, 117 KB) PDF None English
DDE-2468 F-22468 Application For Services Office For The Blind and Visually Impaired Word None English
DDE-2468 F-22468 Application For Services Office For The Blind and Visually Impaired (PDF, 1.3 MB) PDF None English
DPH-07453 F-47453 Application for Tattooist / Body Piercer (PDF, 47 KB) PDF None English
DDE-2640 F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) Word None English
DDE-2640 F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) (PDF, 17 KB) PDF None English
DDE F-20582A Application for Wisconsin’s Children's Long Term Support Programs Word None English
DDE F-20582iA Application for Wisconsin’s Children's Long Term Support Programs, Instructions (PDF, 27KB) PDF None English
DMHSAS F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility Word None English
DPH-07014 F-47014 Application/Permits For Vending Machine Operator - Commissary and Machines Word None English
DDE-2599 F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI) (PDF, 21 KB) PDF None English
DPH-07242 F-47242 Asbestos Certification Application Paper Program English
DPH-44002 F-44002 Asbestos Certification Application - Company (PDF, 104 KB) PDF None English
DPH-44017 F-44017 Asbestos Certification Application - Individual (PDF, 33 KB) PDF None English
DPH-44017S F-44017S Asbestos Certification Application - Individual - Spanish (PDF, 25 KB) PDF None Spanish
DPH F-00039 Asbestos Course Accreditation - Initial (PDF, 83 KB) PDF None English
DPH F-00040 Asbestos Course Accreditation - Renewal (PDF, 27 KB) PDF None English
DPH-44016 F-44016 Asbestos Occupant Protection Plan (PDF, 32 KB) PDF None English
DPH F-00049 Asbestos Principal Instructor (PDF, 30 KB) PDF None English
DPH F-00041 Asbestos Project Notification Word None English
DPH F-00041 Asbestos Project Notification (PDF, 145 KB) PDF None English
DDE-0817 F-20817 Assessment Worksheet for Natural Residential Setting Word None English
DDE-0817 F-20817 Assessment Worksheet for Natural Residential Setting (PDF, 28 KB) PDF None English
DDE-0817A F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses Word None English
DDE-0817A F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses (PDF, 16 KB) PDF None English
DDE-0817S F-20817S Assessment Worksheet for Natural Residential Setting - Spanish (PDF, 23 KB) PDF None Spanish
DDE-0980 F-20980 Assessment/Supplement to the Long Term Care Functional Screen Word None English
DMT-0476 F-80476 Asset Transfer Word None English
DQA F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum Word None English
DQA F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum (PDF, 19 KB) PDF None English
DQA F-00157 Assisted Living Administrator Training Course - Trainer Approval Application Word None English
DQA F-00157 Assisted Living Administrator Training Course - Trainer Approval Application (PDF, 60 KB) PDF None English
OQA-2548 F-62548 Assisted Living Facility Request for Waiver, Approval, Variance, Exception Word None English
OQA-2548 F-62548 Assisted Living Facility Request for Waiver, Approval, Variance, Exception (PDF, 28 KB) PDF None English
DQA F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency (PDF, 9 KB) PDF None English
DHCAA F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Word None English
DHCAA F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections (PDF, 1149 KB) PDF None English
DHCAA F-00286A Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Completion Instructions (PDF, 30 KB) PDF None English
HCF-01082 F-01082 Audiology Terms of Reimbursement (PDF, 53 KB) PDF None English
DES F-80479 Audit Confirmation Request Word None English
DES F-80479 Audit Confirmation Request (PDF, 25 KB) PDF None English
DPH-40057 F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program (PDF, 32 KB) PDF None English
DPH F-00086 Authorization for Final Disposition (PDF, 30 KB) HTML None English
DDE-2565 F-22565 Authorization for Recoupment Caretaker Supplement Word None English
DDE-2565 F-22565 Authorization for Recoupment Caretaker Supplement (CTS)* (PDF, 14 KB) PDF None English
DPH F-42016H Authorization for Release of Confidential HIV Test Results - Hmong (PDF, 41 KB) PDF None Hmong
DPH-42016 F-42016 Authorization for Release of Confidential HIV Test Results (PDF, 512 KB) PDF None English
DPH F-42016S Authorization for Release of Confidential HIV Test Results - Spanish (PDF, 242 KB) PDF None Spanish
DDE-2564 F-22564 Authorization for Retroactive Caretaker Supplement (CTS)* (PDF, 28 KB) PDF None English
OQA-2308 F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail Word None English
OQA-2308 F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail (PDF, 54 KB) PDF None English
HCF-14014 F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF, 199 KB) PDF None English
HCF-14014AS F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 292 KB) PDF None Spanish
DPH F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) (PDF, 34 KB) PDF None English
DPH F-00048H Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) - Hmong (PDF, 29 KB) PDF None Hmong
DPH F-00048S Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) - Spanish (PDF, 130 KB) PDF None Spanish
DPH F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) (PDF, 77 KB) PDF None English
DPH F-00051H Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) - Hmong (PDF, 74 KB) PDF None Hmong
DPH F-00051S Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) - Spanish (PDF, 162 KB) PDF None Spanish
DPH-42029 F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine (PDF, 34 KB) PDF None English
DPH-42029H F-42029H Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine - Hmong (PDF, 28 KB) PDF None Hmong
DPH-42029S F-42029S Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine - Spanish (PDF, 97 KB) PDF None Spanish
DPH-42030 F-42030 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) Vaccine (PDF, 30 KB) PDF None English
DPH-42030H F-42030H Authorization To Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine - Hmong (PDF, 33 KB) PDF None Hmong
DPH-42030S F-42030S Authorization To Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine - Spanish (PDF, 91 KB) PDF None Spanish
DHCAA F-00101 Authorization to Request Birth Records Word None English
DDE-0987 F-20987 Authorized Representative Designation, Medicaid Community Waiver Programs (PDF, 21 KB) PDF None English
DLTC F-20987S Authorized Representative Designation, Medicaid Community Waiver Programs - Spanish (PDF, 21 KB) PDF None Spanish
DDE-1077 F-21077 Autism Treatment Services Criteria Checklist Instructions Word None English
DLTC F-01352 Background Check Appeal Request - IRIS Program Word None English
DQA F-82069 Background Info Disclosure Appendix Word None English
DQA F-82069 Background Info Disclosure Appendix (PDF, 81 KB) PDF None English
HFS-0064 F-82064 Background Information Disclosure (BID) Word Form Center English
HFS-0064 F-82064 Background Information Disclosure (BID) and Instructions (PDF, 52 KB) Paper Form Center English
HFS-0064H F-82064H Background Information Disclosure (BID) and Instructions - Hmong (PDF, 57 KB) PDF None Hmong
HFS-0064H F-82064S Background Information Disclosure (BID) and Instructions - Spanish (PDF, 57 KB) PDF None Spanish
HFS-0064 F-82064A Background Information Disclosure (BID) Instructions only (PDF, 27 KB) Paper Form Center English
DLTC F-01246 Background Information Disclosure Addendum—IRIS Word None English
HCF-10115 F-10115 BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) PDF None English
HCF-10115S F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) PDF None Spanish
HCF-10182 F-10182 BadgerCare Plus Application Packet (PDF, 2417 KB) Paper Form Center English
HCF-10182H F-10182H BadgerCare Plus Application Packet - Hmong (PDF, 1310 KB) PDF None Hmong
HCF-10182S F-10182S BadgerCare Plus Application Packet - Spanish (PDF, 1460 KB) PDF None Spanish
HCF-10183 F-10183 BadgerCare Plus Change Report (PDF, 345 KB) Paper Form Center English
HCF-10183H F-10183H BadgerCare Plus Change Report - Hmong (PDF, 284 KB) PDF None Hmong
HCF-10183S F-10183S BadgerCare Plus Change Report - Spanish (PDF, 340 KB) PDF None Spanish
HCF-10185 F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication Word None English
HCF-11309 F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification (PDF, 93 KB) PDF None English
HCF-10081 F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application Paper Form Center English
DHCAA F-10081A BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 100 KB) PDF None English
HCF-11268 F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification (PDF, 83 KB) PDF None English
HCF-10184 F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) Word None English
HCF-12085 F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice Paper Program English
HCF-13025 F-13025 BadgerCare Plus Premium Employer Wage Withholding (PDF, 92 KB) PDF None English
HCF-10139 F-10139 BadgerCare Plus Premium Information / Payment (PDF, 76 KB) PDF None English
HCF-10139S F-10139S BadgerCare Plus Premium Information / Payment - Spanish (PDF, 37 KB) PDF None Spanish
HCF-13026 F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer (PDF, 202 KB) PDF None English
HCF-10138 F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) PDF None English
DHCAA F-00914 BadgerCare Plus Tax Filer Information (PDF, 238 KB) PDF None English
DHCAA F-00914S BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) PDF None Spanish
DHCAA F-00914A BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) PDF None English
DMT-0890-CO F-80890-CO BD County Workbook (Profile Expense / Budget Summary, Profile Funding Summary, Listing of Expected Contracts)  Excel None English
DMT-0890 F-80890 BD Workbook (Profile Expense / Budget Summary, Profile Funding Summary, Listing of Expected Contracts, Operating Budget/Supplement)  Excel None English
DPH-07217 F-47217 Bed and Breakfast Inspection Report (PDF, 22 KB) PDF Form Center English
DLTC F-00299 Bedhold Billing Occupancy Test Worksheet Excel None English
DLTC F-01346 Behavior Monitoring Record-Model (PDF, 144 KB) PDF None English
DHCF F-00922 Behavioral Health Integrated Care Health Home Certification Application Word None English
DHCF F-00922 Behavioral Health Integrated Care Health Home Certification Application (PDF, 380 KB) PDF None English
DQA F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Word None English
DQA F-00273 Behavioral Health Services Initial Certification Application - DHS 94 (PDF, 123 KB) PDF None English
DQA F-00276 Behavioral Health Services Renewal Certification Application - DHS 94 and 92 Word None English
DQA F-00276 Behavioral Health Services Renewal Certification Application - DHS 94 and 92 (PDF, 43 KB) PDF None English
DMT-0806A F-80806A Bid Solicitation Results Word None English
DPH-05004 F-05004 Birth Amendment - Affidavit Paper Program English
DPH-05033 F-05033 Birth Amendment - Baptismal Paper Program English
DPH-05291 F-05291 Birth Certificate Application - Wisconsin (PDF, 88 KB) PDF None English
DPH-05291S F-05291S Birth Certificate Application - Wisconsin - Spanish (PDF, 135 KB) PDF None Spanish
DPH-05034 F-05034 Birth Certificate Facts Paper Program English
DPH-40056 F-40056 Birth Defects Prevention and Surveillance System User Security and Confidentiality Agreement (PDF, 21 KB) PDF None English
DDE-2550 F-22550 Birth to 3 Program Parental Cost Share Word None English
DDE-2550 F-22550 Birth to 3 Program Parental Cost Share (PDF, 96 KB) PDF None English
DDE-2550S F-22550S Birth to 3 Program Parental Cost Share - Spanish (PDF, 126 KB) PDF None Spanish
DLTC F-00389 Birth to 3 Program Provider Report of Revenue Word None English
DLTC F-00632S Birth to 3 Program System of Payments and Consent to Access Private Insurance and Medicaid Spanish Word None Spanish
DLTC F-00632S Birth to 3 Program System of Payments and Consent to Access Private Insurance and Medicaid Spanish (PDF, 42 KB) PDF None Spanish
DLTC F-00632_ Birth to 3 Program System of Payments and Consent to Access Private Insurance and/or Medicaid, FORM & PUBLICATION Word None English
DLTC F-00632_ Birth to 3 Program System of Payments and Consent to Access Private Insurance and/or Medicaid, FORM & PUBLICATION (PDF, 35 KB) PDF None English
HCF-01131 F-01131 Blood Banks Terms of Reimbursement (PDF, 41 KB) PDF None English
DPH F-00017 Blood Lead Lab Reporting Word None English
HCF-01127 F-01127 Border Status Hospitals Terms of Reimbursement (PDF, 38 KB) PDF None English
DPH-04764 F-44764 Bracelet Inserts Paper Program English
HCF-01153 F-01153 Breast Pump Order (PDF, 26 KB) PDF None English
DES F-00759 Business Associate Agreement - With Contract Word None English
DPH-07206 F-47206 Campground Inspection Report Paper Form Center English
DPH F-45039 Campground Plan Approval Application (PDF, 251 KB) PDF None English
DMT-0477A F-80477A Canteen Operations Analysis of Cash (GAAP Basis) Excel None English
DMT-0477B F-80477B Canteen Operations Balance Sheet (GAAP Basis) Excel None English
DMT-0477 F-80477 Canteen Operations Statement of Revenues / Expenses and Fund Equity Changes (GAAP Basic) Excel None English
DMT-0963 F-80963 Capital Asset Changes / Deletion Record Word None English
DMT-0462 F-80462 Capital Asset Summary Excel None English
DPH-43015 F-43015 Cardiovascular / Lipid Consultation Record (PDF, 84 KB) PDF None English
OQA-2281 F-62281 Care Level Change Notice Word None English
OQA-2281 F-62281 Care Level Change Notice (PDF, 56 KB) PDF None English
OQA-2288 F-62288 Care Level Determination Worksheet (PDF, 36 KB) PDF None English
DQA F-00161 Caregiver Misconduct Reporting Requirements Worksheet Word None English
DQA F-00161 Caregiver Misconduct Reporting Requirements Worksheet (PDF, 68 KB) PDF None English
OQA-2520 F-62520 Caregiver Program Compliance Check Word None English
DQA F-62520 Caregiver Program Compliance Check (PDF, 38 KB) PDF None English
DHCAA F-00476 CARES Automated Systems Access Request Word None English
DHCAA F-00476A CARES Automated Systems Access Request Completion Instructions (PDF, 31 KB) PDF None English
DLTC F-00052B CARES Data Access and Use Agreement (ADRC) Word None English
DDE-22571A F-22571A Caretaker Supplement (CTS) Instructions for Application (PDF, 47 KB) PDF None English
DDE-2571AS F-22571AS Caretaker Supplement (CTS) Instructions for Application - Spanish (PDF, 54 KB) PDF None Spanish
DDE-22571 F-22571 Caretaker Supplement Application (PDF, 218 KB) PDF None English
DMT-0883 F-80883 CARS Contract Adjustment - Extensions and Moves Word None English
DMT-0862 F-80862 CARS Expenditure Report by Activity Excel None English
DMT-0855 F-80855 CARS Expenditure Report by Profile  Excel None English
DMT-0865 F-80865 CARS Expense Adjustment Report Word None English
HCF-01086 F-01086 Case Management Terms of Reimbursement (PDF, 43 KB) PDF None English
DMT-1011 F-81011 Cash Certification for Contingent, Canteen client / Resident and General Accounts Word None English
DPH-05044 F-05044 Cause of Death Amendment Paper Program English
DQA F-00012 CBRF Completion Documents (PDF, 18 KB) PDF None English
OQA-0290 F-60290 CBRF Identification of Hazards Request Word None English
OQA-0290 F-60290 CBRF Identification of Hazards Request (PDF, 15 KB) PDF None English
DQA F-01216 CCS for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application Word None English
DQA F-01216 CCS for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application (PDF, 315 KB) PDF None English
DQA F-00482 CCS Initial Certification Application - DHS 36, F-00482 Word None English
DQA F-00482 CCS Initial Certification Application - DHS 36, F-00482 (PDF, 164 KB) PDF None English
DQA F-00014 Ceiling Closure Inspection Checklist Word None English
DQA F-00014 Ceiling Closure Inspection Checklist (PDF, 22 KB) PDF None English
DPH-45011 F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License Word None English
DPH-45011 F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License (PDF, 21 KB) PDF None English
DPH-45007 F-45007 Certificate of Disposition of Materials Word None English
DPH-45007 F-45007 Certificate of Disposition of Materials (PDF, 17 KB) PDF None English
DPH-45023 F-45023 Certificate Use of Depleted Uranium under General License (PDF, 308 KB) PDF None English
DPH-44003 F-44003 Certification Application - Individual Lead-Based Paint Activities and Investigations - Note:  Information and Instructions are attached (PDF, 69 KB) PDF None English
DDE-0818 F-20818 Certification for SSI-E Exceptional Expense Supplement Word None English
DDE-0818 F-20818 Certification for SSI-E Exceptional Expense Supplement (PDF, 75 KB) PDF None English
DDE-0818S F-20818S Certification for SSI-E Exceptional Expense Supplement - Spanish (PDF, 71 KB) PDF None Spanish
DMT-0601 F-80601 Certification of Claim* (PDF, 18 KB) PDF None English
HCF-01162 F-01162 Certification of Emergency for Non-U.S. Citizens (PDF, 12 KB) PDF None English
HCF-01162A F-01162A Certification of Emergency for Non-U.S. Citizens (PDF, 21 KB) PDF None English
DQA F-00191 Certified Outpatient Clinic Request for a Branch Office Word None English
DQA F-00191 Certified Outpatient Clinic Request for a Branch Office (PDF, 31 KB) PDF None English
DQA F-00191A Certified Outpatient Clinic Request for a School Branch Office (PDF, 31 KB) PDF None English
DQA F-00191A Certified Outpatient Clinic Request for a School Branch Office (PDF, 31 KB) Word None English
OQA-2586 F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide Word None English
OQA-2586 F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide (PDF, 56 KB) PDF None English
DPH-07470 F-47470 Change of EMS Medical Director Word None English
DPH-07470 F-47470 Change of EMS Medical Director (PDF, 65 KB) PDF None English
DLTC F-00615 Change Project Report Word None English
HCF-01148 F-01148 Chapter 150 Program, Application for Renewing the Approval of a Distinct Part Facility for the Developmentally Disabled (FDD) Word None English
DMT-0188 F-80188 Check Distribution / Attachments Word Form Center English
DLTC F-00989A Child and Family Information (IFSP) Word None English
HCF-01118A F-01118A Child Care Coordination Family Questionnaire Completion Instructions(PDF, 10 KB) PDF None English
HCF-01118 F-01118 Child Care Coordination Family Questionnaire (PDF, 241 KB) PDF None English
DLTC F-00479 Child Outcomes Fidelity Self-Assessment Word None English
DLTC F-00480 Child Outcomes Summary Word None English
DLTC F-00316 Child Status Regarding Birth to 3 Program Word None English
DLTC F-00316S Child Status Regarding Birth to 3 Program - Spanish Word None Spanish
DLTC F-00989H Child/Family Outcome (IFSP) Word None English
DLTC F-00367 Children's Long Term Support (CLTS) Programs Functional Screen (FS) (PDF, 163 KB) PDF None English
DDE-1232 F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet Word None English
DLTC F-00539 Children's Long Term Support Service Coordination Rate Worksheet Excel None English
DLTC F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application Word None English
DLTC F-21080A Children's Long-Term Support Waivers Application Checklist - Step Two Word None English
DDE-1080 F-21080 Children's Long-Term Support Waivers Eligibility Verification - Step One Word None English
DLTC F-00102 Children's Long-Term Support Waivers HSRS Slot Change Request Word None English
DLTC F-00102 Children's Long-Term Support Waivers HSRS Slot Change Request (PDF, 34 KB) PDF None English
DDE-1078 F-21078 Children's Long-Term Support Waivers Recertification Checklist Word None English
DDE-0911 F-20911 Children's Long-Term Support Waivers, Intensive In-Home Autism Treatment Services: Rights, Responsibilities and Requirements (PDF, 22 KB) PDF None English
DDE-0911H F-20911H Children's Long-Term Support Waivers, Intensive In-Home Autism Treatment Services: Rights, Responsibilities and Requirements - Hmong (PDF, 22 KB) PDF None Hmong
DDE-0911S F-20911S Children's Long-Term Support Waivers, Intensive In-Home Autism Treatment Services: Rights, Responsibilities and Requirements - Spanish (PDF, 20 KB) PDF None Spanish
DPH-40071 F-40071 Children's Physical Activity Chart (PDF, 18 KB) PDF None English
DLTC F-00963 Children’s Long Term Support Reconciliation Packet Excel None English
DLTC F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report Word None English
HCF-01088 F-01088 Chiropractor Terms of Reimbursement (PDF, 42 KB) PDF None English
DDE-0394 F-20394 CIP II Community Relocation Initiative 30-day / 90-day Questionnaire Word None English
DDE-0415 F-20415 CIP II Nursing Home Diversion Request Coversheet Word None English
DES F-80983B Civil Rights Complaint - Burmese (PDF, 32 KB) PDF None Burmese
DES F-00167 Civil Rights Complaint Consent/Release Word None English
DES F-00167AL Civil Rights Complaint Consent/Release - Albanian (PDF, 19 KB) PDF None Albanian
DES F-00167AR Civil Rights Complaint Consent/Release - Arabic (PDF, 87 KB) PDF None Arabic
DES F-00167BU Civil Rights Complaint Consent/Release - Burmese (PDF, 69 KB) PDF None Burmese
DES F-00167CC Civil Rights Complaint Consent/Release - Cantonese (PDF, 197 KB) PDF None Cantonese
DES F-00167FA Civil Rights Complaint Consent/Release - Farsi (PDF, 59 KB) PDF None Farsi
DES F-00167H Civil Rights Complaint Consent/Release - Hmong (PDF, 20 KB) PDF None Hmong
DES F-00167KH Civil Rights Complaint Consent/Release - Khmer (PDF, 51 KB) PDF None Khmer
DES F-00167KR Civil Rights Complaint Consent/Release - Korean (PDF, 132 KB) PDF None Korean
DES F-00167L Civil Rights Complaint Consent/Release - Laotian (PDF, 173 KB) PDF None Laotian
DES F-00167CM Civil Rights Complaint Consent/Release - Mandarin (PDF, 239 KB) PDF None Mandarin
DES F-00167R Civil Rights Complaint Consent/Release - Russian (PDF, 63 KB) PDF None Russian
DES F-00167SE Civil Rights Complaint Consent/Release - Serbian (PDF, 60 KB) PDF None Serbian
DES F-00167SO Civil Rights Complaint Consent/Release - Somali (PDF, 20 KB) PDF None Somali
DES F-00167S Civil Rights Complaint Consent/Release - Spanish (PDF, 20 KB) PDF None Spanish
DES F-00167V Civil Rights Complaint Consent/Release - Vietnamese (PDF, 94 KB) PDF None Vietnamese
DES F-80983S Civil Rights Complaint Form - Spanish (PDF, 20 KB) PDF None Spanish
DES F-80983AB Civil Rights Complaint Instructions - Burmese (PDF, 32 KB) PDF None Burmese
DES F-80983H Civil Rights Compliance Complaint (PDF, 17 KB) PDF None Hmong
DES F-80983AH Civil Rights Compliance Complaint Instructions - Hmong (PDF, 19 KB) PDF None Hmong
DES F-00165 Civil Rights Compliance Letter of Assurance Word None English
DES F-00164 Civil Rights Compliance Plan Word None English
DMT-0983 F-80983 Civil Rights Discrimination Complaint Word None English
DMT-0983 F-80983 Civil Rights Discrimination Complaint (PDF, 19 KB) PDF None English
DMT-0983A F-80983A Civil Rights Discrimination Complaint Instructions (PDF, 19 KB) PDF None English
HCF-13066 F-13066 Claim Refund Word None English
HCF-13066 F-13066 Claim Refund (PDF, 69 KB) PDF None English
HCF-13066A F-13066A Claim Refund Completion Instructions (PDF, 32 KB) PDF None English
DMT-0459 F-80459 Client Account Balance Report Excel None English
DDE-6100 F-26100 Client Rights Limitation or Denial Documentation Word None English
DDE-6100 F-26100 Client Rights Limitation or Denial Documentation (PDF, 28 KB) PDF None English
DDE-6100S F-26100S Client Rights Limitation or Denial Documentation - Spanish Word None Spanish
DDE-6100S F-26100S Client Rights Limitation or Denial Documentation - Spanish (PDF, 31 KB) PDF None Spanish
DDE-6100A F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement Word None English
DDE-6100A F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement (PDF, 11 KB) PDF None English
DMHSAS F-00660A Client Rights Office Consult Question Word None English
OQA-2470 F-62470 Client/Patient/Resident Death Determination Word None English
OQA-2470 F-62470 Client/Patient/Resident Death Determination (PDF, 76 KB) PDF None English
DDE-1284 F-21284 Clinician Confirmation of Diagnosis Word None English
DLTC F-00367J CLTS FS, Age-Specific ADL / IADL, 12 to 14 Years (PDF, 32 KB) PDF None English
DLTC F-00367C CLTS FS, Age-Specific ADL / IADL, 12 to 18 Months (PDF, 25 KB) PDF None English
DLTC F-00367K CLTS FS, Age-Specific ADL / IADL, 14 to 18 Years (PDF, 33 KB) PDF None English
DLTC F-00367D CLTS FS, Age-Specific ADL / IADL, 18 to 24 Months (PDF, 24 KB) PDF None English
DLTC F-00367L CLTS FS, Age-Specific ADL / IADL, 18 Years and Up (PDF, 34 KB) PDF None English
DLTC F-00367E CLTS FS, Age-Specific ADL / IADL, 24 to 36 Months (PDF, 28 KB) PDF None English
DLTC F-00367F CLTS FS, Age-Specific ADL / IADL, 36 Months to 4 Years (PDF, 30 KB) PDF None English
DLTC F-00367G CLTS FS, Age-Specific ADL / IADL, 4 to 6 Years (PDF, 29 KB) PDF None English
DLTC F-00367B CLTS FS, Age-Specific ADL / IADL, 6 to 12 Months (PDF, 24 KB) PDF None English
DLTC F-00367H CLTS FS, Age-Specific ADL / IADL, 6 to 9 Years (PDF, 32 KB) PDF None English
DLTC F-00367i CLTS FS, Age-Specific ADL / IADL, 9 to 12 Years (PDF, 31 KB) PDF None English
DLTC F-00367A CLTS FS, Age-Specific ADL / IADL, Birth to 6 Months (PDF, 23 KB) PDF None English
DLTC F-01338 CLTS Parental Fee Declaration-Model Word None English
DLTC F-00950 CMS 10003-NDMCP, Notice of Denial of Medical Coverage Word None English
DDE-2687 F-22687 Collaborative Systems of Care (CSOC) Plan of Care (PDF, 39 KB) PDF None English
DDE-2688 F-22688 Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide (PDF, 34 KB) PDF None English
DDE-2685 F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment (PDF, 45 KB) PDF None English
DMT-0142 F-80142 Collections Delegation Application Word None English
DMHSAS F-00153 Commitment to Offer Community Recovery Services (CRS) Word None English
DLTC F-00043 Communication to Local Educational Agency Regarding Child Referral Word None English
OQA-0367 F-60367 Community Advisory Committee Documentation Word None English
OQA-0367 F-60367 Community Advisory Committee Documentation (PDF, 10 KB) PDF None English
OQA-0795 F-60795 Community Based Residential Facility (CBRF) Fire Inspection Word None English
OQA-0795 F-60795 Community Based Residential Facility (CBRF) Fire Inspection (PDF, 24 KB) PDF None English
OQA-0287 F-60287 Community Based Residential Facility (CBRF) Initial License Application Word None English
OQA-0287 F-60287 Community Based Residential Facility (CBRF) Initial License Application (PDF, 90 KB) PDF None English
OQA-2416 F-62416 Community Based Residential Facility (CBRF) Initial Licensure Checklist Word None English
OQA-2416 F-62416 Community Based Residential Facility (CBRF) Initial Licensure Checklist (PDF, 24 KB) PDF None English
OQA-2372 F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation Word None English
OQA-2372 F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation (PDF, 35 KB) PDF None English
OQA-2430 F-62430 Community Based Residential Facility Residents' Rights Complaint Report Word None English
OQA-2430 F-62430 Community Based Residential Facility Residents' Rights Complaint Report (PDF, 59 KB) PDF None English
DDE-1051 F-21051 Community Long Term Care Services Referral to Income Maintenance Worker Word None English
DDE-1051 F-21051 Community Long Term Care Services Referral to Income Maintenance Worker (PDF, 30 KB) PDF None English
DDE-1228 F-21228 Community Mental Health Services Block Grant - County Reporting Word None English
DMHSAS F-00251 Community Mental Health Services Block Grant - County Reporting Word None English
DDE-1353 F-21353 Community Options Program (COP) Exceptional Expense Request Word None English
DLTC F-00539A Community Options Program Support Service Coordination Rate Worksheet Excel None English
DMHSAS F-00260 Community Recovery Services - Service Plan Packet Quality Review Results Word None English
OIG F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB) PDF None English
DDE-2678 F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate Word None English
DDE-2678 F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate (PDF, 103 KB) PDF None English
HCF-10096 F-10096 Community Spouse Asset Share Notice (PDF, 658 KB) PDF None English
HCF-10096S F-10096S Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) PDF None Spanish
DQA F-00523 Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03 Word None English
DQA F-00523 Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03 (PDF, 126 KB) PDF None English
OQA F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 Word None English
OQA F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 (PDF, 39 KB) PDF None English
OQA-2504 F-62504 Community Substance Abuse Services (CSAS) or Mental Health Clinic Initial Certification Application Restricted None English
DQA F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) Word None English
DQA F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) (PDF, 39 KB) PDF None English
DDE-0009 F-20009 Complaint Report (PDF, 10 KB) PDF None English
DDE-0009S F-20009S Complaint Report - Spanish (PDF, 18 KB) PDF None Spanish
OQA-2495 F-62495 Compliance Statement Word None English
OQA-2495 F-62495 Compliance Statement (PDF, 30 KB) PDF None English
HCF-13073 F-13073 Compound Drug Claim Word None English
HCF-13073 F-13073 Compound Drug Claim (PDF, 60 KB) PDF None English
HCF-13073A F-13073A Compound Drug Claim Completion Instructions (PDF, 27 KB) PDF None English
DMHSAS F-00230 Comprehensive Community Services Detailed Budget Plan Request Word None English
DQA F-00475 Comprehensive Community Services for Persons with Mental Disorders and Substance-Use Disorders Recertification Application Chapter DHS 36 Word None English
DQA F-00475 Comprehensive Community Services for Persons with Mental Disorders and Substance-Use Disorders Recertification Application Chapter DHS 36 (PDF, 49 KB) PDF None English
DHCAA F-01270 Comprehensive Community Services Non-Traditional Approval PDF None English
DHCAA F-01270 Comprehensive Community Services Non-Traditional Approval Word None English
DMHSAS F-21365 Comprehensive Community Services Startup Outcomes - 2009 Word None English
DDE-6110 F-26110 Conditional Release / Supervised Release Program Invoice Word None English
DDE-6110 F-26110 Conditional Release / Supervised Release Program Invoice (PDF, 32 KB) PDF None English
DDE-6110I F-26110I Conditional Release / Supervised Release Program Invoice Instructions (PDF, 11 KB) PDF None English
DDE-5614 F-25614 Conditional Release Rules and Conditions Word None English
DDE-5614 F-25614 Conditional Release Rules and Conditions (PDF, 15 KB) PDF None English
DDE-5614H F-25614H Conditional Release Rules and Conditions - Hmong Word None Hmong
DDE-5614H F-25614H Conditional Release Rules and Conditions - Hmong (PDF, 26 KB) PDF None Hmong
DDE-5614S F-25614S Conditional Release Rules and Conditions - Spanish Word None Spanish
DDE-5614S F-25614S Conditional Release Rules and Conditions - Spanish (PDF, 15 KB) PDF None Spanish
DPH-40054 F-40054 Confidential Birth Defects Registry Report (PDF, 188 KB) PDF None English
HFS-0009H F-82009H Confidential Information Release Authorization - Hmong (PDF, 29 KB) PDF None Hmong
DES F-82009BU Confidential Information Release Authorization - Burmese (PDF, 34 KB) PDF None Burmese
HFS-0009 F-82009 Confidential Information Release Authorization - Generic (PDF, 19 KB) PDF None English
HFS-0009S F-82009S Confidential Information Release Authorization - Generic - Spanish (PDF, 22 KB) PDF None Spanish
HFS-0009 F-82009 Confidential Information Release Authorization - Generic  Word None English
HFS-0009AA F-82009AA Confidential Information Release Authorization - Katie Beckett Program Paper Form Center English
HFS-0009AAH F-82009AAH Confidential Information Release Authorization - Katie Beckett Program - Hmong (PDF, 63 KB) PDF None Hmong
DES F-82009RU Confidential Information Release Authorization - Russian (PDF, 137 KB) PDF None Russian
HFS-0009S F-82009S Confidential Information Release Authorization - Spanish Word None Spanish
  F-82009TC Confidential Information Release Authorization for Transportation Complaint Research Word None English
DLTC F-00695 Connections to Community Living Non-MDS Referral and Tracking Word None English
DLTC F-21336 Consent for Exchange of Information with Local Educational Agency Word None English
DLTC F-21336S Consent for Exchange of Information with Local Educational Agency - Spanish Word None Spanish
HCF-01164 F-01164 Consent for Sterilization Word None English
HCF-01164 F-01164 Consent for Sterilization (PDF, 123 KB) PDF None English
HCF-01164S F-01164S Consent for Sterilization - Spanish (PDF, 23 KB) PDF None Spanish
HCF-01164S F-01164S Consent for Sterilization - Spanish (PDF, 23 KB) Word None Spanish
HCF-01164A F-01164A Consent for Sterilization Instructions (PDF, 119 KB) PDF None English
DMHSAS F-00397 Consent of Disclosure of Information - Multiple Registration Central Registry Word None English
DLTC F-00632 Consent to Access Private Insurance and/or Medicaid Word None English
DLTC F-00632 Consent to Access Private Insurance and/or Medicaid (PDF, 22 KB) PDF None English
DDE-2538 F-22538 Consent to Film or Tape Word None English
DDE-2538 F-22538 Consent to Film or Tape (PDF, 12 KB) PDF None English
DDE-2538S F-22538S Consent to Film or Tape - Spanish (PDF, 12 KB) PDF None Spanish
DDE-2538S F-22538S Consent to Film or Tape - Spanish (PDF, 12 KB) Word None Spanish
DPH F-00758 Consent to Pierce - Release and Waiver of All Claims (PDF, 119 KB) PDF None English
DPH F-00758A Consent to Pierce Minor - Release and Waiver of All Claims (PDF,126 KB) PDF None English
DLTC F-00688 Consent to Release Medical and Birth-3 Information/Referral to Birth-3 Word None English
DPH F-00757 Consent to Tattoo Procedure - Release and Waiver of All Claims (PDF, 121 KB) PDF None English
DHCAA F-00628 Consortium Response to the State IM Second Party Review Finding Word None English
DHCAA F-00628 Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) PDF None English
DDE-2491 F-22491 Consumer Report - OBVI Word None English
DMT-0952A F-80952A Contingency Plan, DHS Regional Offices Word None English
DMT-0952 F-80952 Contingency Plan, Health and Human Services Agencies Word None English
DMT-0761 F-80761 Contingent Account Activity Report Excel None English
DES F-00724 Contract Performance - Payment Bond Form Word None English
DMT-0882 F-80882 Contract Summary (CARS) Word None English
DMHSAS F-01416 Coordinated Service Team (CST) Initiative Detailed Budget Plan Excel None English
DDE-9322 F-29322 COP Cost-Share Worksheet # 3 (PDF, 29 KB) PDF None English
DDE-9320 F-29320 COP Cost-Share Worksheet #1 Instructions (PDF, 27 KB) PDF None English
DDE-9321 F-29321 COP Cost-Share Worksheet #2 (PDF, 19 KB) PDF None English
DDE-9319 F-29319 COP Cost-Share Worksheet (PDF, 25 KB) PDF None English
DDE-9314 F-29314 COP Declaration of Income and Assets and State Residency (PDF, 52 KB) PDF None English
DDE-9318 F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP (PDF, 32 KB) PDF None English
DDE-0823 F-20823 COP Functional Screen (PDF, 134 KB) PDF Form Center English
DDE-9316 F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant (PDF, 26 KB) PDF None English
DDE-9317 F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply (PDF, 32 KB) PDF None English
DPH-05044C F-05044C Corner/Medical Examiner - Cause of Death Amendment Word Program English
OQA-2546 F-62546 Corporate Guardianship Program Annual Report Word None English
OQA-2546 F-62546 Corporate Guardianship Program Annual Report (PDF, 31 KB) PDF None English
OQA-0820 F-60820 Corporate Guardianship Program Status Application Word None English
OQA-0820 F-60820 Corporate Guardianship Program Status Application (PDF, 31 KB) PDF None English
DQA F-60820A Corporate Guardianship Program Status Application Instructions and Checklist Word None English
DQA F-60820A Corporate Guardianship Program Status Application Instructions and Checklist (PDF, 45 KB) PDF None English
DMHSAS F-00203 County / Tribal Agency Application - Wisconsin Home and Community Based Services, Community Recovery Services (CRS) Word None English
DDE-1231 F-21231 County Agency Contacts Regarding Children at MMHI / WMHI Word None English
DDE-1199 F-21199 County Agency Treatment Report Word None English
DLTC F-00388 County Birth to 3 Fiscal Reconciliation Report Word None English
DLTC F-00388i County Birth to 3 Fiscal Reconciliation Report - Instructions PDF None English
DLTC F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records Word None English
DLTC F-00634S County Birth to 3 Program Annual Notification of Parental Rights Regarding Records, Spanish Word None Spanish
DLTC F-00634i County Birth to 3 Program Annual Notification of Parental Rights Regarding Records-Instructions (PDF, 444 KB) PDF None English
DLTC F-00634iS County Birth to 3 Program Annual Notification of Parental Rights Regarding Records-Instructions, Spanish (PDF, 81 KB) PDF None Spanish
DDE-0822 F-20822 County Review of Nursing Home, IMD or ICF / MR Referrals Word None English
DDE-0822 F-20822 County Review of Nursing Home, IMD or ICF / MR Referrals (PDF, 17 KB) PDF None English
DPH-05054 F-05054 Court Order To Amend Cause of Death - 89 Paper Program English
DPH-05098 F-05098 Court Order to Correct Facts, Misrepresented Information Paper Program English
DPH-44029 F-44029 Credit Card Payment (PDF, 66 KB) PDF None English
DPH-44029S F-44029S Credit Card Payment - Spanish (PDF, 28 KB) PDF None Spanish
DDE-0452 F-20452 Criteria for High Risk of Nursing Home Admission (PDF, 77 KB) PDF None English
DQA F-00518 CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 Word None English
DQA F-00518 CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 (PDF, 518 KB) PDF None English
DQA F-00466 CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08 Word None English
DQA F-00466 CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08 (PDF, 54 KB) PDF None English
DQA F-00515 CSAS Day Treatment Service Initial Certification Application - DHS 75.12 Word None English
DQA F-00515 CSAS Day Treatment Service Initial Certification Application - DHS 75.12 (PDF, 68 KB) PDF None English
DQA F-00470 CSAS Day Treatment Service Recertification Application - DHS 75.12 Word None English
DQA F-00470 CSAS Day Treatment Service Recertification Application - DHS 75.12 (PDF, 55 KB) PDF None English
DQA F-00473 CSAS Intervention Service Recertification Application - DHS 75.16 Word None English
DQA F-00473 CSAS Intervention Service Recertification Application - DHS 75.16 (PDF, 63 KB) PDF None English
DQA F-00537 CSAS Intervention Services Initial Certification Application - DHS 75.16 Word None English
DQA F-00537 CSAS Intervention Services Initial Certification Application - DHS 75.16 (PDF, 43 KB) PDF None English
DQA F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 Word None English
DQA F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 (PDF, 25 KB) PDF None English
DQA F-00464 CSAS Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 Word None English
DQA F-00464 CSAS Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 (PDF, 52 KB) PDF None English
DQA F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 Word None English
DQA F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 (PDF, 37 KB) PDF None English
DQA F-00468 CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 Word None English
DQA F-00468 CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 (PDF, 61 KB) PDF None English
DQA F-00519 CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 Word None English
DQA F-00519 CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 (PDF, 27 KB) PDF None English
DQA F-00465 CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 Word None English
DQA F-00465 CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 (PDF, 56 KB) PDF None English
DQA F-00514 CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 Word None English
DQA F-00514 CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 (PDF, 41 KB) PDF None English
DQA F-00469 CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11 Word None English
DQA F-00469 CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11 (PDF, 62 KB) PDF None English
DQA F-00538 CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 Word None English
DQA F-00538 CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 (PDF, 104 KB) PDF None English
DQA F-00472 CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 Word None English
DQA F-00472 CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 (PDF, 64 KB) PDF None English
DQA F-00302 CSAS Outpatient Clinic Recertification Application - DHS 75.13 Word None English
DQA F-00302 CSAS Outpatient Clinic Recertification Application - DHS 75.13 (PDF, 51 KB) PDF None English
DQA F-00544 CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13 Word None English
DQA F-00544 CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13 (PDF, 30 KB) PDF None English
DQA F-00521 CSAS Prevention Service Initial Certification Application - DHS 75.04 Word None English
DQA F-00521 CSAS Prevention Service Initial Certification Application - DHS 75.04 (PDF, 36 KB) PDF None English
DQA F-00517 CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 Word None English
DQA F-00517 CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 (PDF, 31 KB) PDF None English
DQA F-00467 CSAS Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 Word None English
DQA F-00467 CSAS Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 (PDF, 59 KB) PDF None English
DQA F-00027 CSAS Standards Recertification Application - DHS 75.03 Word None English
DQA F-00027 CSAS Standards Recertification Application - DHS 75.03 (PDF, 58 KB) PDF None English
DQA F-00513 CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 Word None English
DQA F-00513 CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 (PDF, 35 KB) PDF None English
DQA F-00471 CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14 Word None English
DQA F-00471 CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14 (PDF, 60 KB) PDF None English
DPH-40041 F-40041 CSFP Certification & Food Package Pick-Up For Seniors (PDF, 21 KB) PDF Form Center English
DPH-40041H F-40041H CSFP Certification & Food Package Pick-Up For Seniors - Hmong (PDF, 22 KB) PDF Form Center Hmong
DPH-40041R F-40041R CSFP Certification & Food Package Pick-Up For Seniors - Russian (PDF, 156 KB) PDF Form Center Russian
DPH-40041S F-40041S CSFP Certification & Food Package Pick-Up For Seniors - Spanish (PDF, 156 KB) PDF Form Center Spanish
DPH-40028R F-40028R CSFP Ineligibility, Termination, and Waiting List - Russian Paper Form Center Russian
DPH-40028S F-40028S CSFP Ineligibility, Termination, and Waiting List - Spanish Paper Form Center Spanish
DPH-40044 F-40044 CSFP Rights and Responsibilities (PDF, 31 KB) PDF Form Center English
DPH-40044H F-40044H CSFP Rights and Responsibilities - Hmong Paper Form Center Hmong
DPH-40044R F-40044R CSFP Rights and Responsibilities - Russian Paper Form Center Russian
DPH-40044S F-40044S CSFP Rights and Responsibilities - Spanish Paper Form Center Spanish
DQA F-00546 CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 Word None English
DQA F-00546 CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 (PDF, 54 KB) PDF None English
DPH-45020 F-45020 Cumulative Occupational Exposure History (PDF, 149 KB) PDF None English
DPH-04192 F-44192 Day Care Immunization Record (PDF, 553 KB) PDF Form Center English
DPH-05280 F-05280 Death Certificate Application (PDF, 72 KB) PDF None English
DPH-05280S F-05280S Death Certificate Application - Spanish (PDF, 118 KB) PDF None Spanish
DDE-0465 F-20465 Declaration of Income (PDF, 32 KB) PDF None English
DDE-0465S F-20465S Declaration of Income - Spanish (PDF, 35 KB) PDF None Spanish
DDE-0919D F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program Word None English
DDE-0919D F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program (PDF, 28 KB) PDF None English
DPH F-00060 Declaration to Physicians (Living Will) (PDF, 27 KB) HTML Program English
DPH F-00060A Declaration To Physicians (Living Will) - Letter PDF Program English
DPH-05046 F-05046 Delayed Death - Court Order Paper Program English
HFS-0002 F-82002 Denial of Government Access To Health Care Records (PDF, 13 KB) PDF None English
HFS-0003 F-82003 Denial of Researcher Access To Health Care Records (PDF 14 KB) PDF None English
HCF-01092 F-01092 Dental - Dental Hygienists Terms of Reimbursement (PDF, 42 KB) PDF None English
DMT-0475 F-80475 Department Training Registration System None English
DMT-0141 F-80141 Deposit Voucher Excel None English
DPH F-00047 Designated Asbestos Coordinator (PDF, 39 KB) PDF None English
HCF-16004 F-16004 Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (PDF, 32 KB) PDF None English
HCF-16004H F-16004H Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong (PDF, 31 KB) PDF None Hmong
HCF-16004S F-16004S Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish (PDF, 33 KB) PDF None Spanish
DLTC F-00889 Designation of Confidential and Proprietary Information- Managed LTC Business Plan Word None English
DLTC F-00889 Designation of Confidential and Proprietary Information- Managed LTC Business Plan (PDF, 46 KB) PDF None English
DDE-1072 F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting Word None English
DDE-0922 F-20922 Determination of No Active Treatment (NAT) Rating (PDF, 14 KB) PDF None English
DLTC F-01348 Determining the Weighted Care Management Rate-Direct Service Staff Worksheet CM-I (Model) (PDF, 37 KB) PDF None English
DPH F-43009 Diabetes Emergency Action Plan (PDF, 122 KB) PDF none English
DPH F-43013 Diabetes Medical Management Plan (PDF, 587 KB) PDF NONE English
HCF-16060 F-16060 Disaster FoodShare Wisconsin Assistance Application (PDF, 118 KB) PDF None English
HCF-16060S F-16060S Disaster FoodShare Wisconsin Assistance Application - Spanish (PDF, 75 KB) PDF None Spanish
HCF-16025 F-16025 Disqualification Consent Agreement (PDF, 71 KB) PDF None English
HCF-16025S F-16025S Disqualification Consent Agreement - Spanish (PDF, 72 KB) PDF None Spanish
DQA F-00728 Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix Word None English
DQA F-00728 Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix (PDF, 150 KB) PDF None English
DPH-05282 F-05282 Divorce Certificate Application - Wisconsin (PDF, 60 KB) PDF None English
DPH-05282S F-05282S Divorce Certificate Application - Wisconsin - Spanish (PDF, 107 KB) PDF None Spanish
DLTC/DMHSAS F-00037C DLTC and DMHSAS Memo Series E-Mail Subscription Services Sign-Up HTML None English
DMHSAS F-21276AA DMHSAS Mini Grant/Contract Application – Coordinated Services Teams (CST) Program Word None English
DDE-1276 F-21276 DMHSAS Annual Grant/Contract Application Word None English
DMHSAS F-21276A DMHSAS Coordinated Services Teams (CST) Grant/Contract Application Summary Word None English
DDE-0389 F-20389 DMHSAS Program Performance Report Word None English
DDE-0389 F-20389 DMHSAS Program Performance Report (PDF, 56 KB) PDF None English
DPH-43025 F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation (PDF, 261 KB) PDF None English
DPH-43025 F-43025S Document of Anatomical Gift Authorization for Organ and Tissue Donation (PDF, 376 KB) PDF None Spanish
DDE-0971 F-20971 Documentation of Training - Supportive Home Care (SHC) / Respite Word None English
OQA-2096 F-62096A DQA Authority for Obtaining Provider Records Without Written Release (PDF, 59 KB) PDF None English
DQA F-00037D DQA E-Mail Subscription Service Sign-Up HTML None English
DHCAA F-00020 Drug Addition Review Request Word None English
DHCAA F-00020 Drug Addition Review Request (PDF, 653 KB) PDF None English
OQA-2644 F-62644 Drug Repository Program Donation, Transfer, and Destruction Record Word None English
OQA-2644 F-62644 Drug Repository Program Donation, Transfer, and Destruction Record (PDF, 61 KB) PDF None English
OQA-2643 F-62643 Drug Repository Program Notice of Participation or Withdrawal Word None English
OQA-2643 F-62643 Drug Repository Program Notice of Participation or Withdrawal (PDF, 62 KB) PDF None English
OQA-2645 F-62645 Drug Repository Program Recipient Record Word None English
OQA-2645 F-62645 Drug Repository Program Recipient Record (PDF, 58 KB) PDF None English
DPH-05218 F-05218 E-mail Notification Request For New Publication Release HTML None English
DPH-00303 F-40303 Early Childhood Caries Prevention Screening (PDF, 117 KB) PDF None English
DLTC F-00317 Early Intervention Team Report - Eligibility Determination - Birth to 3 Word None English
DLTC F-00317 Early Intervention Team Report - Eligibility Determination - Birth to 3 (PDF, 28 KB) PDF None English
DLTC F-00317S Early Intervention Team Report - Eligibility Determination - Birth to 3 - Spanish Word None Spanish
DLTC F-00989F Early Intervention Team Report/Wisconsin Early Intervention Eligibility Determination (IFSP) Word None English
DLTC F-00528 Elder Abuse Direct Service Funds Application Word None English
DLTC F-00528 Elder Abuse Direct Service Funds Application (PDF, 14 KB) PDF None English
DDE-1150 F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers Word None English
DMT-0602 F-80602 Electronic Expenditure Report Certification (PDF, 15 KB) PDF None English
DMT-0602 F-80602 Electronic Expenditure Report Certification  Word None English
DHCAA F-00343 Eligibility Management (Income Maintenance) Policy Notification Sign-Up HTML None English
DPH-04763 F-44763 Emergency Care - Do Not Resuscitate Order (DNR) Paper Program English
DPH-40070 F-40070 Emergency Feeding Organization (EFO) Monitoring Instrument Word None English
DPH F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan Word None english
DPH F-00646 Emergency Medical Service Training Center - Training Eligibility Certification Word None English
DPH-07482 F-47482 Emergency Medical Service Training Center Certification Application (PDF, 84 KB) PDF None English
DPH-07489 F-47489 Emergency Medical Services (EMS) Patient Care Worksheet (PDF, 620 KB) PDF None English
DPH F-00567 Emergency Medical Services Complaint Word None English
DPH-07255 F-47255 Emergency Medical Services Funding Assistance Program Application (State Fiscal Year 2014) Word None English
DPH-07463B F-47463B Emergency Medical Techician (EMT) - Basic Operational Plan Components (PDF, 26 KB) PDF None English
DPH-07463D F-47463D Emergency Medical Techician (EMT) - Intermediate Operational Plan Components (PDF, 26 KB) PDF None English
DPH-07463C F-47463C Emergency Medical Techician (EMT) - Intermediate Technician Operational Plan Components (PDF, 721 KB) PDF None English
DPH-07472 F-47472 Emergency Medical Techician (EMT) License / First Responder Certification Renewal Application System None English
DPH-07463E F-47463E Emergency Medical Technician (EMT) - Paramedic Operational Plan Components (PDF, 27 KB) PDF None English
DPH-07464 F-47464 Emergency Medical Technician - Basic IV Training Permit Application (PDF, 160 KB) PDF None English
DPH-07128 F-47128 Emergency Medical Technician - Basic Training Permit Application (PDF, 711 KB) PDF None English
DPH-07125 F-47125 Emergency Medical Technician - Intermediate Training Permit Application (PDF, 233 KB) PDF None English
DPH-07471 F-47471 Emergency Medical Technician Verification of Licensure System None English
DPH-07141 F-47141 Emergency Medical Technician-Paramedic Training Permit Application (PDF, 160 KB) PDF None English
DQA F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 Word None English
DQA F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 (PDF, 144 KB) PDF None English
DQA F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 Word None English
DQA F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 (PDF, 51 KB) PDF None English
DQA F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 Word None English
DQA F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 (PDF, 37 KB) PDF None English
DDE-2559 F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors (PDF, 21 KB) PDF None English
DHCAA F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) PDF None English
DMT-0976 F-80976 Employment and Education History Summary Word None English
DMT-0976 F-80976 Employment and Education History Summary (PDF, 19 KB) PDF None English
HFS-0006 F-82006 Employment Application / Applicant Registration Supplement Word None English
HFS-0006 F-82006 Employment Application / Applicant Registration Supplement (PDF, 47 KB) PDF None English
HCF-10146 F-10146 Employment Verification of Earnings Word None English
DPH F-00568 EMS Board Sub-Committee Appointment Application Word None English
DPH F-00987B EMS Service Operational Plan Advanced Skills Addendum – Advanced EMT Word None English
DPH F-00987E EMS Service Operational Plan Advanced Skills Addendum – Critical Care Word None English
DPH F-00987 EMS Service Operational Plan Advanced Skills Addendum – EMT-Basic Word None English
DPH F-00987C EMS Service Operational Plan Advanced Skills Addendum – First Responder Word None English
DPH F-00987A EMS Service Operational Plan Advanced Skills Addendum – Intermediate Word None English
DPH F-00987D EMS Service Operational Plan Advanced Skills Addendum – Paramedic Word None English
DLTC F-21334 Encounter New User Request Word None English
HCF-11318 F-11318 Enrollment Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus (PDF, 38 KB) PDF None English
HCF-11317 F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus (PDF, 45 KB) PDF None English
OQA-2296 F-62296 Entrance Conference Checklist Word None English
DPH-40040 F-40040 Envelope - No. 9 Vendor and Integrity Unit Address Paper Form Center English
DPH-09027 F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey Paper Program English
HCF-13039 F-13039 Estate Recovery Program (ERP) Disclosure (PDF, 30 KB) PDF None English
HCF-13039A F-13039A Estate Recovery Program (ERP) Disclosure Instructions (PDF, 20 KB) PDF None English
HCF-13174 F-13174 Estate Recovery Program (ERP) Heir Information (PDF, 101 KB) PDF None English
DDE-1063 F-21063 Exception to Care Management/Support and Service Coordination Contact Requirements Word None English
DDE-1063 F-21063 Exception to Care Management/Support and Service Coordination Contact Requirements (PDF, 14 KB) PDF None English
EXEC F-00943 Exhibit II - Tribal Work Plan Word None English
DLTC F-00037A Expanding Adults-at-Risk in Wisconsin Listserv Sign-Up HTML None English
DHCF F-00898 Explanation of Medicare Benefits for Diabetic Supply Claims Word None English
DHCF F-00898 Explanation of Medicare Benefits for Diabetic Supply Claims (PDF, 1341 KB) PDF None English
DHCF F-00898A Explanation of Medicare Benefits for Diabetic Supply Claims Completion Instructions (PDF, 35 KB) PDF None English
OQA-9261 F-69261 Extended / Partial Extended Survey Worksheet CMS-673 Paper Form Center English