Department of Health Services Logo

 

Wisconsin Department of Health Services

Forms Home

Publications Home

About PDF Documents

Alphabetic Forms Lists

A - E

F - M

N - Z

Numeric Lists

F - 0
F - 1
F - 2
F - 4
F - 6
F - 8

Division/Office
Numeric Lists

CFS
DES
DLTC
DMHSAS
DPH
DQA
EXS
HCAA
HFS

Division Prefix Definitions

Cannot Find a Form?

Order Printed Forms

Order WI  Administrative Codes or Statutes

 

Ordering Paper Forms from the Forms/Publications Center

To order a form or publication in paper format that is stored in the Forms/Publications Center, please select option 1 or 2 below:

  1. Ordering via US Mail (F-80025)

  1. Ordering electronically, using Microsoft Word (F-80025A and B)  
    Note:  You must have Microsoft Word 97 or newer to complete this form.

Use the list below to identify the form number and title for your order. If you do not find the form you are looking for, it may be available only in electronic format. Review the lists available in the left border of this page to find all electronic forms. View the list of publications available from the forms/publications center.

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
DHCAA F-00243 Community Recovery Services Mental Health / Substance Abuse Welcome Enrollment Packet Paper Form Manager English
DLTC F-00315 Written Prior Notice - Birth to 3 PDF Form Center English
DLTC F-00315 Written Prior Notice - Birth to 3 Word Form Center English
DHCAA F-00341 Community Recovery Services Terms of Reimbursement Paper Form Manager English
HCF-01105 F-01105 Pre-Natal Care Coordination Pregnancy Questionnaire PDF Form Center English
HCF-01112 F-01112 HealthCheck Verification Card Paper Form Center English
HCF-01118 F-01118 ForwardHealth Child Care Coordination Family Questionnaire PDF Form Center English
DPH-04020 F-04020 Student Immunization Record Paper Form Center English
DPH-04020L F-04020L Student Immunization Record PDF Form Center English
DPH-04020LH F-04020LH Student Immunization Record - Hmong PDF Form Center Hmong
DPH-04020LS F-04020LS Student Immunization Record - Spanish PDF Form Center Spanish
DPH-04020S F-04020S Student Immunization Record - Spanish Paper Form Center Spanish
DPH-05021 F-05021 Report of Legal Name Change Paper Form Center English
DPH-05103 F-05103 Facts About Your Child's Birth Certificate Paper Form Center English
DPH-05104 F-05103S Facts About Your Child's Birth Certificate - Spanish Paper Form Center Spanish
DPH-05191 F-05191 Vital Records Fee Schedule Paper Form Center English
HCF-10075 F-10075 Wisconsin Well Woman Medicaid Determination PDF Form Center English
HCF-10076 F-10076 SeniorCare Application PDF Form Center English
HCF-10076A F-10076A SeniorCare Instructions for Application Form PDF Form Center English
HCF-10081 F-10081 BadgerCare Plus - Express Enrollment for Pregnant Women Application Paper Form Center English
HCF-10101 F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet PDF Form Center English
HCF-10109 F-10109 Medicaid Remaining Deductible Update PDF Form Center English
HCF-10112 F-10112 Medicaid Disability Application PDF Form Center English
HCF-10119 F-10119 Temporary Enrollment For Family Planning Only Services Paper Form Center English
HCF-10137 F-10137 Medicaid Change Report PDF Form Center English
HCF-10182 F-10182 BadgerCare Plus Application / Review Packet PDF Form Center English
HCF-10183 F-10183 BadgerCare Plus Change Report PDF Form Center English
HCF-10183H F-10183H BadgerCare Plus Change Report - Hmong PDF Form Center Hmong
HCF-10183S F-10183S BadgerCare Plus Change Report - Spanish PDF Form Center Spanish
HCF-12081 F-12081 Wisconsin Medicaid Health Information Exchange Facility Security and Confidentiality Agreement Paper Form Manager English
HCF-12085 F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice Paper Form Manager English
HCF-13038 F-13038 Notice of Intent to File a Lien Paper Form Center English
HCF-16006 F-16006 FoodShare Wisconsin Change Report PDF Form Center English
HCF-16019A F-16019A FoodShare Wisconsin Registration / Important Information PDF Form Center English
HCF-16019B F-16019B FoodShare Wisconsin Application / Registration PDF Form Center English
HCF-16066 F-16066 FoodShare Wisconsin Income Change Report PDF Form Center English
HCF-16104 F-16104 Local Agency Customer Feedback PDF Form Center English
HCF-16104S F-16104S Local Agency Customer Feedback - Spanish PDF Form Center Spanish
DDE-0031 F-20031 Core Human Services Reporting System PDF Form Center English
DDE-0031I F-20031I HSRS Core Deskcard PDF Form Center English
DDE-0458 F-20458 HSRS Alcohol and Other Drug Abuse Module PDF Form Center English
DDE-0458I F-20458I HSRS AODA Module Desk card PDF Form Center English
DDE-0468 F-20468 HSRS Family Support Program Module PDF Form Center English
DDE-0468I F-20468I HSRS Family Support Program Module Desk card PDF Form Center English
DDE-0817 F-20817 Assessment Worksheet for Natural Residential Setting PDF Form Center English
DDE-0817 F-20817 Assessment Worksheet for Natural Residential Setting Word Form Center English
DDE-0823 F-20823 COP Functional Screen PDF Form Center English
DDE-0855 F-20855 HSRS Mental Health Module PDF Form Center English
DDE-0855 F-20855 HSRS Mental Health Module Word Form Center English
DDE-0855I F-20855I HSRS Mental Health Module Desk card PDF Form Center English
DDE-2018 F-22018 HSRS Long Term Support Module (Human Services Reporting System) PDF Form Center English
DDE-2018I F-22018I HSRS Long-Term Support Module Desk card PDF Form Center English
DDE-5311 F-25311 Notification to Victims of Offenders Paper Form Center English
DDE-5534 F-25534 Notification to Victims of Sexually Violent Persons Paper Form Center English
DPH-40028 F-40028 Commodity Supplemental Food Program (CSFP) Ineligibility, Termination, and Waiting List Paper Form Center English
DPH-40028R F-40028R Commodity Supplemental Food Program (CSFP) Ineligibility Letter - Russian Paper Form Center English
DPH-40028S F-40028S Commodity Supplemental Food Program (CSFP) Ineligibility Letter -Spanish Paper Form Center Spanish
DPH-40040 F-40040 Envelope - No. 9 Vendor and Integrity Unit Address Paper Form Center English
DPH-40041 F-40041 Commodity Supplemental Food Program (CSFP) Food Package Pick-Up For Seniors PDF Form Center English
DPH-40041H F-40041H Food Package Pickup Form - Seniors - Hmong PDF Form Center Hmong
DPH-40041R F-40041R Commodity Supplemental Food Program (CSFP) Certification Seniors - Russian PDF Form Center Russian
DPH-40041S F-40041S Food Package Pickup Form - Seniors - Spanish PDF Form Center Spanish
DPH-40042 F-40042 Commodity Supplemental Food Program (CSFP) Certification-Mothers and Children PDF Form Center English
DPH-40042H F-40042H Food Package Pickup Form- Mother/Child - Hmong Paper Form Center Hmong
DPH-40042R F-40042R Food Package Pickup Form - Mother/Child - Russian Paper Form Center Russian
DPH-40042S F-40042S Food Package Pickup Form - Mother/Child - Spanish Paper Form Center Spanish
DPH-40044 F-40044 Commodity Supplemental Food Program (CSFP) Rights and Responsibilities Paper Form Center English
DPH-40044H F-40044H Commodity Supplemental Food Program (CSFP) Rights and Responsibilities-Hmong Paper Form Center Hmong
DPH-40044R F-40044R Commodity Supplemental Food Program (CSFP) Rights and Responsibilities-Russian Paper Form Center Russian
DPH-40044S F-40044S Commodity Supplemental Food Program (CSFP) Rights and Responsibilities - Spanish Paper Form Center Spanish
DPH-40076 F-40076 Women, Infants, and Children (WIC) Nutrition Program Income Statement PDF Form Center English
DPH-40076S F-40076S Women, Infants, and Children (WIC) Nutrition Program Income Statement - Spanish PDF Form Center Spanish
DPH-40103 F-40103 Senior Farmer's Market Nutrition Program Paper Form Center English
DPH-40103H F-40103H Senior Farmer's Market Nutrition Program Paper Form Center English
DPH-40103S F-40103S Senior Farmer's Market Nutrition Program Paper Form Center English
DPH-00117 F-40117 Abortion Information Provision Certification PDF Form Center English
DPH-00117A F-40117A Entrega de Información Sobre Abortos PDF Form Center Spanish
DPH-40123A F-40123A Hearing Screening Postcard - English Paper Form Center English
DPH-40123AH F-40123AH Hearing Screening Postcard - Hmong Paper Form Center English
DPH-40123AS F-40123AS Hearing Screening Postcard - Spanish Paper Form Center English
DPH-42018 F-42018 Consent For Anonymous - Confidential Rapid HIV Test Paper Form Center English
DPH-42018S F-42018S Consentimiento Para Prueba Rapida De HIV Paper Form Center Spanish
DPH-42020 F-42020 Envelope - Window No. 10 Security Redi-Strip Paper Form Center English
DPH-42021 F-42021 Envelope - No. 10 Security Paper Form Center English
DPH-42028 F-42028 Envelope - 10 x 13 Confidential Postage Paid Paper Form Center English
DPH-42029 F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine PDF Form Center English
DPH-42030 F-42030 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) Vaccine PDF Form Center English
DPH-43016 F-43016 Prevent Heart Disease & Stroke Wallet Card Paper Form Center English
DPH-43016H F-43016H Personal Heart Care Record Card - Hmong Paper Form Center Hmong
DPH-43016S F-43016S Personal Heart Care Record Card - Spanish Paper Form Center Spanish
DPH-44027 F-44027 Wisconsin Asthma Questionnaire Paper Form Center English
DPH-04089 F-44089 Wisconsin WIC Checks Accepted Here - Stickers Paper Form Center English
DPH-04151 F-44151 Acute and Communicable Disease Case Report PDF Form Center English
DPH-04151 F-44151 Acute and Communicable Disease Case Report Word Form Center English
DPH-04158 F-44158 Women, Infant, and Children (WIC) Application Brochure/Postcard Paper Form Center English
DPH-04158H F-44158H Women, Infant, and Children (WIC) Application Brochure/Postcard - Spanish Paper Form Center Hmong
DPH-04158S F-44158S Women, Infant, and Children (WIC) Application Brochure/Postcard - Spanish Paper Form Center Spanish
DPH-04160A F-44160A Plastic Cover - For Women, Infant, and Children (WIC) ID Folder Paper Form Center English
DPH-04160L F-44160L Women, Infant, and Children (WIC) Folder Paper Form Center English
DPH-04160LS F-44160LS Women, Infant, and Children (WIC) Folder - Spanish Paper Form Center Spanish
DPH-04161 F-44161 Women, Infant and Children (WIC) Rights and Responsibilities PDF Form Center English
DPH-04161H F-44161H Women, Infant and Children (WIC) Rights and Responsibilities - Hmong PDF Form Center Hmong
DPH-04161S F-44161S Women, Infant, and Children (WIC) Rights and Responsibilities - Spanish PDF Form Center Spanish
DPH-04192 F-44192 Day Care Immunization Record PDF Form Center English
DPH-04192S F-44192S Registro de Inmunizaciones para Guardería Infantil (Day Care Immunization Record) PDF Form Center English
DPH-04236 F-44236 Pertussis Case Report PDF Form Center English
DPH-04243 F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report Word Form Center English
DPH-04257 F-44257 Wisconsin Immunization Record Card Paper Form Center English
DPH-04287 F-44287 VIP Appointment Card Paper Form Center English
DPH-04289 F-44289 VIP Immunization Record Card 3 X 5 Paper Form Center English
DPH-04291 F-44291 Dear Parent VIP Postcard Paper Form Center English
DPH-04292 F-44292 VIP Immunization Record 6 X 4 Paper Form Center English
DPH-04465A F-44465A Vaccinate Promptly Paper Form Center English
DPH-04659 F-44659 Wisconsin WIC / Farmers Market Nutrition Program Input Record Paper Form Center English
DPH-04702 F-44702 Vaccine Administration Record PDF Form Center English
DPH-04702S F-44702S Vaccine Administration Record - Spanish PDF Form Center Spanish
DPH-04727 F-44727 Women, Infant, and Children (WIC) Vendor Training Paper Form Center English
DPH-04750 F-44750 Inspection Report - Supplement PDF Form Center English
DPH 4756 F-44756 Wisconsin Tuberculosis Record Card Paper FormsCenter English
DPH 4756H F-44756H Wisconsin Tuberculosis Record Card - Hmong Paper FormsCenter Hmong
DPH 4756S F-44756S Wisconsin Tuberculosis Record Card - Spanish Paper FormsCenter Spanish
DPH-04828 F-44828 Make Your Smile Count - Oral Screening Paper Form Center English
DPH-45000 F-45000 Termination of Order To Cease Operation Paper Form Center English
DPH-45002A F-45002A Restaurant/Retail Food Service Inspection Report Paper Form Center English
DPH-45002B F-45002B Restaurant/Retail Food Service Inspection Report Page 2 Paper Form Center English
DPH-45002C F-45002C Restaurant/Retail Food Service Inspection Report Page 3 Paper Form Center English
DPH-45004 F-45004 Temporary Restaurant Inspection Report Paper Form Center English
DPH-45029 F-45029 School Food Safety Program Inspection Report Paper Form Center English
DPH-45029I F-45029I Instructions For School Food Safety Plan Paper Form Center English
DPH-45030 F-45030 Inspection Narrative Paper Form Center English
DPH-45031 F-45031 Waterslide Inspection Report Paper Form Center English
DPH-05702 F-45702 Healthy Smiles For Head Start Paper Form Center English
DPH-07018 F-47018 State of Wisconsin Permit Application to Operate a Mobile Restaurant / Mobile Service Base Word Form Center English
DPH-07205 F-47205 Swimming Pool Inspection Report PDF Form Center English
DPH-07206 F-47206 Campground Inspection Report Paper Form Center English
DPH-07208 F-47208 Recreational / Educaional Camp Inspection Report Paper Form Center English
DPH-07208A F-47208A Additional Page for Recreational Sanitation Paper Form Center English
DPH-07217 F-47217 Bed and Breakfast Inspection Report PDF Form Center English
DPH-07221 F-47221 Conditional Permit Paper Form Center English
DPH-07223 F-47223 Order to Cease Operation Paper Form Center English
DPH-07224 F-47224 Termination of Order to Cease Operation Paper Form Center English
DPH-07337 F-47337 Application for Registration of Tanning Devices PDF Form Center English
DPH-07345 F-47345 Restaurant Manager Certification - Brown Paper Form Center English
DPH-07450 F-47450 License, Permit or Registration (Purple Ink) Paper Form Center English
DPH-07454 F-47454 Tattoo and Body Piercing Inspection Report PDF Form Center English
DPH-07461A F-47461A Label-Wash Paper Form Center English
DPH-07461B F-47461B Label-Rinse Paper Form Center English
DPH-07461C F-47461C Label-Sanatize Paper Form Center English
DPH-07461D F-47461D Label-Prewash Paper Form Center English
DPH-07462 F-47462 Envelope - Bureau of Emergency Medical Services No. 10 / No Endorsement Paper Form Center English
DPH-09045 F-49045 Center for Disease Control (CDC) 73.2936s Field Record Paper Form Center English
DPH-09357 F-49357 Personal Diabetes Care Record PDF Form Center English
DPH-09357H F-49357H Personal Diabetes Care Record Hmong PDF Form Center Hmong
DPH-09357S F-49357S Personal Diabetes Care Record Spanish PDF Form Center Spanish
OQA-9251 F-69251 Hospice Request For Certification In The Medicare Program Paper Form Center English
OQA-9259 F-69259 Long Term Care Facility Application For Medicare and Medicaid Cms671 Paper Form Center English
OQA-9260 F-69260 Resident Census and Conditions of Residents CMS-672 Paper Form Center English
OQA-9305A F-69305A Provider Instructions For HCFA-802 Paper Form Center English
DMT-0025 F-80025 Forms / Publications Requisition Paper Form Center English
DMT-0188 F-80188 Check Distribution / Attachments Word Form Center English
HFS-0009II F-82009II Confidential Information Release Authorization - WIC (Version Date: 05/03) PDF Form Center English
HFS-0009IIS F-82009IIS Confidential Information Release Authorization - WIC - Spanish (Version Date: 05/03) PDF Form Center Spanish
HFS-0018C F-82018C Work Time Absence Record - 2012 Excel - Fillable Form Center English
HFS-0018C F-82018C Work Time Absence Record - 2012 Excel - PRINT Form Center English
HFS-0064 F-82064 Background Information Disclosure and Instructions PDF Form Center English
HFS-0064 F-82064 Background Information Disclosure and Instructions Word Form Center English

Last Revised:  November 02, 2010