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Forms: N to Z

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
DPH-05210 F-05210 Name Change Request Within 1st Year Paper Program English
HCF-16001 F-16001 Negative Notice Word None English
HCF-16001 F-16001 Negative Notice (PDF, 154 KB) PDF None English
HCF-16001S F-16001S Negative Notice - Spanish Word None Spanish
HCF-16001S F-16001S Negative Notice - Spanish (PDF, 200 KB) PDF None Spanish
DMT-0962 F-80962 New Capital Asset Record Word None English
HCF-10180 F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) PDF None English
DPH F-00986 Newborn Screening Program - Condition Nomination Word None English
DLTC F-00888 Next Steps (PDF, 89 KB) Paper Form Center English
DPH-07198 F-47198 Noise Exposure Sampling Sheet Paper Program English
DMT-0751 F-80751 Non-County Resident Proceedings Cost Certification Word None English
DMT-0751 F-80751 Non-County Resident Proceedings Cost Certification (PDF, 18 KB) PDF None English
HCF-13072 F-13072 Noncompound Drug Claim Word None English
HCF-13072 F-13072 Noncompound Drug Claim (PDF, 547 KB) PDF None English
HCF-13072A F-13072A Noncompound Drug Claim Completion Instructions (PDF, 50 KB) PDF None English
DLTC F-00633 Notice and Consent for Screening Word None English
DLTC F-00633 Notice and Consent for Screening (PDF, 85 KB) PDF None English
DLTC F-00633s Notice and Consent for Screening - Spanish (PDF, 100 KB) PDF None Spanish
HCF-16024 F-16024 Notice of Disqualification (PDF, 110 KB) PDF None English
HCF-16024S F-16024S Notice of Disqualification - Spanish (PDF, 50 KB) PDF None Spanish
HCF-16028 F-16028 Notice of FoodShare Over issuance (PDF, 288 KB) PDF None English
HCF-16028S F-16028S Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) PDF None Spanish
HCF-01147 F-01147 Notice of Intent - Chapter 150 Program, Long Term Care / Resource Allocation Program Word None English
HCF-13038 F-13038 Notice of Intent to File a Lien Paper Form Center English
DLTC F-00053 Notice of Intent to Submit an Application (ADRC) Word None English
DLTC F-00575 Notice of Intent to Submit an Application for Tribal Aging & Disability Resource Specialist (TADRS) Word None English
HCF-16014 F-16014 Notice of Program Violation (PDF, 43 KB) PDF None English
DPH-05043 F-05043 Notice of Removal - Corpse (Hospital, Nursing Home, Hospice) Paper Program English
HCF-10099 F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB) PDF None English
DQA F-62594 Notice of Substantial Change Feeding Assistant Training Program Word None English
DQA F-62594 Notice of Substantial Change Feeding Assistant TrainingProgram (PDF, 24 KB) PDF None English
OQA-2224 F-62224 Notice of Substantial Change Nurse Aide Training Program Word None English
OQA-2224 F-62224 Notice of Substantial Change Nurse Aide Training Program (PDF, 22 KB) PDF None English
DPH-44012 F-44012 Notification of Lead-Based Paint Activity (PDF, 31 KB) PDF None English
DDE-2638 F-22638 Notification of Waiver Program Termination Word None English
DDE-2638 F-22638 Notification of Waiver Program Termination (PDF, 14 KB) PDF None English
DLTC F-22638S Notification of Waiver Program Termination - Spanish Word None Spanish
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
DQA F-00385 Nurse Aide Training - Student Waiver Word None English
DQA F-00385 Nurse Aide Training - Student Waiver (PDF, 20 KB) PDF None English
OQA-2610 F-62610 Nurse Aide Training Program Primary Instructor Application Word None English
OQA-2610 F-62610 Nurse Aide Training Program Primary Instructor Application (PDF, 25 KB) PDF None English
DQA F-62687 Nurse Aide Training Program Trainer Application Word None English
DQA F-62687 Nurse Aide Training Program Trainer Application (PDF, 25 KB) PDF None English
HCF-01504 F-01504 Nurse Midwife Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01509 F-01509 Nurse Practitioner Terms of Reimbursement (PDF, 42 KB) PDF None English
DPH-04771B F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels Word None English
DPH-04771B F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels (PDF, 558 KB) PDF None English
DPH-04771A F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels* Word None English
DPH-04771A F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels* (PDF, 28 KB) PDF None English
DLTC F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System Word None English
DQA F-00311 Nursing Home MDS 3.0 Section Q Referral Word None English
DQA F-00311 Nursing Home MDS 3.0 Section Q Referral (PDF, 66 KB) PDF None English
OQA-2151 F-62151 Nursing Home Residents' Rights Complaint Report Word None English
OQA-2151 F-62151 Nursing Home Residents' Rights Complaint Report (PDF, 32 KB) PDF None English
DQA F-00907 OASIS Assessment Deletion Request Word None English
DQA F-00907 OASIS Assessment Deletion Request (PDF, 17 KB) PDF None English
DLTC F-00321 OBVI Initial Interview Assessment Word None English
DPH F-00201 Occupant Protection Plan (Checklist for Lead-Based Paint Activities) (PDF, 34 KB) PDF None English
DPH-45003 F-45003 Occupational Exposure Record Per Monitoring Period (PDF, 89 KB) PDF None English
HCF-01512 F-01512 Occupational Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
DDE-0224 F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation Word None English
DMT-0115 F-80115 Operating Budget Excel None English
DMT-0115A F-80115A Operating Budget Supplement Excel None English
DMT-0456 F-80456 Operating Lease Agreement Word None English
DPH-07236 F-47236 Operations and Maintenance Certificate Paper Program English
DLTC F-00169 Opting Out of LEA Notification (PDF, 16 KB) PDF None English
DLTC F-00169S Opting Out of LEA Notification - Spanish (PDF, 22 KB) PDF None Spanish
DLTC F-00780 Options Counseling Tip Card Paper Form Center English
HCF-01514 F-01514 Optometrist / Optician Terms of Reimbursement (PDF, 42 KB) PDF None English
DLTC F-00050 Oral Health Preliminary Exam and Prevention Services (PDF, 43 KB) PDF None English
DDE-5207 F-25207 Order Granting Capias Word None English
DDE-5207 F-25207 Order Granting Capias (PDF, 20 KB) PDF None English
DDE-5180 F-25180 Order of Discharge Upon Expiration of Commitment Word None English
DDE-5180 F-25180 Order of Discharge Upon Expiration of Commitment (PDF, 16 KB) PDF None English
DPH-04817 F-44817 Order To Cease Operation Paper Program English
DDE-5205 F-25205 Order to Transport Word None English
DDE-5205 F-25205 Order to Transport (PDF, 11 KB) PDF None English
DQA F-00059 Outpatient Mental Health Clinic Application - DHS 35 Word None English
DQA F-00059 Outpatient Mental Health Clinic Application - DHS 35 (PDF, 87 KB) PDF None English
DQA F-00380 Outpatient Mental Health Clinic Certification Withdrawal Word None English
DQA F-00380 Outpatient Mental Health Clinic Certification Withdrawal (PDF, 29 KB) PDF None English
DQA F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist Word None English
DQA F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist (PDF, 45 KB) PDF None English
DQA F-00785 Outpatient Mental Health Clinic Recertification Application Word None English
DQA F-00785 Outpatient Mental Health Clinic Recertification Application (PDF, 54 KB) PDF None English
DLTC F-00534 PACE / Partnership Member Requested Disenrollment Word None English
DLTC F-00534i PACE / Partnership Member Requested Disenrollment - Instructions (PDF, 19 KB) PDF None English
DLTC F-00533 PACE / Partnership Programs - Enrollment Word None English
DDE-0985 F-20985 Participant Rights and Responsibilities Notification (PDF, 25 KB) PDF None English
DDE-0985H F-20985H Participant Rights and Responsibilities Notification - Hmong (PDF, 49 KB) PDF None Hmong
DDE-0985S F-20985S Participant Rights and Responsibilities Notification - Spanish (PDF, 50 KB) PDF None Spanish
EXEC F-83294 Partner Endorsement: Joint Statement and Guide to Action Word None English
DLTC F-00681 Partnership - Managed Care Organization (MCO) Options Word None English
DPH-05020A F-05020A Paternity Order Due to Divorce - Custody Paper Program English
DPH-05020 F-05020 Paternity Order Due to Divorce - Judgement Paper Program English
DPH F-00653a Patient Data Import Training Excel None English
DPH-45025 F-45025 Patient Questionnaire Paper Program English
DPH F-00703 Patient Side Training Report (PDF, 86 KB) PDF None English
HCF-01813 F-01813 Patients by Payer Source on Last Day of Quarter Excel None English
DPH-40075 F-40075 Pedometer Walking Program (PDF, 83 KB) PDF None English
DQA F-00119 Personal Care Agency Application for Approval (PDF, 9 KB) PDF None English
DQA F-00262 Personal Care Agency Application Materials Checklist Word None English
DQA F-00262 Personal Care Agency Application Materials Checklist (PDF, 18 KB) PDF None English
DQA F-00262a Personal Care Agency Application Regulatory Guidance Checklist PDF None English
DQA F-00262a Personal Care Agency Application Regulatory Guidance Checklist Word None English
DQA F-62651A Personal Care Agency Calendar Worksheet - Prescribed Visists Word None English
DQA F-62651A Personal Care Agency Calendar Worksheet - Prescribed Visits (PDF, 13 KB) PDF None English
DQA F-00784 Personal Care Agency Client Rights Word None English
DQA F-00784 Personal Care Agency Client Rights (PDF, 19 KB) PDF None English
DQA F-62069A Personal Care Agency Complaint Report Word None English
DQA F-62069A Personal Care Agency Complaint Report (PDF, 25 KB) PDF None English
DQA F-62274A Personal Care Agency Consent for Home Visit Word None English
DQA F-62274A Personal Care Agency Consent for Home Visit (PDF, 17 KB) PDF None English
DQA F-62274AH Personal Care Agency Consent for Home Visit - Hmong Word None Hmong
DQA F-62274AH Personal Care Agency Consent for Home Visit - Hmong (PDF, 16 KB) PDF None Hmong
DQA F-62274S Personal Care Agency Consent for Home Visit - Spanish Word None Spanish
DQA F-62274S Personal Care Agency Consent for Home Visit - Spanish (PDF, 17 KB) PDF None Spanish
DQA F-62652A Personal Care Agency Home Visit Guide Word None English
DQA F-62652A Personal Care Agency Home Visit Guide (PDF, 24 KB) PDF None English
DQA F-00261 Personal Care Agency Personnel Record Review Word None English
DQA F-00261 Personal Care Agency Personnel Record Review (PDF, 10 KB) PDF None English
DQA F-00263 Personal Care Agency Record Review Word None English
DQA F-00263 Personal Care Agency Record Review (PDF, 18 KB) PDF None English
DQA F-62648A Personal Care Agency Sample Selection Word None English
DQA F-62648A Personal Care Agency Sample Selection (PDF, 12 KB) PDF None English
DQA F-00264 Personal Care Agency Surveyor Guide Word None English
DQA F-00264 Personal Care Agency Surveyor Guide (PDF, 62 KB) PDF None English
HCF-01516 F-01516 Personal Care Terms of Reimbursement (PDF, 42 KB) PDF None English
DPH-09357 F-49357 Personal Diabetes Care Record (PDF, 152 KB) PDF Form Center English
DPH-09357S F-49357S Personal Diabetes Care Record - Spanish (PDF, 102 KB) PDF Form Center Spanish
DPH-04236 F-44236 Pertussis Case Report (PDF, 292 KB) PDF None English
OQA-2537 F-62537 Petition for Building Code Variance Word None English
OQA-2537 F-62537 Petition for Building Code Variance (PDF, 44 KB) PDF None English
DDE-5206 F-25206 Petition for Capias Word None English
DDE-5206 F-25206 Petition for Capias (PDF, 21 KB) PDF None English
DDE-5393 F-25393 Petition for Conditional Release Word None English
DDE-5392 F-25392 Petition for Re-examination Word None English
DMT-0013 F-80013 Petty Cash Fund Annual Report Excel None English
DHCAA F-00841 Pharmacy Services Lock-In Program HMO Referral for Pharmacy Services Lock-In of HMO Member PDF None English
DHCAA F-00841 Pharmacy Services Lock-In Program HMO Referral for Pharmacy Services Lock-In of HMO Member Word None English
DHCAA F-00840 Pharmacy Services Lock-In Program HMO Responsibilities for Member Referral to Pharmacy PDF None English
DHCAA F-00840 Pharmacy Services Lock-In Program HMO Responsibilities for Member Referral to Pharmacy Word None English
DHCAA F-00842 Pharmacy Services Lock-In Program Summary PDF None English
HCF-01518 F-01518 Pharmacy Terms of Reimbursement (PDF, 49 KB) PDF None English
DPH-40092 F-40092 Physical Activity Zone (PDF, 229 KB) PDF None English
DMT-0464 F-80464 Physical and Capital Inventory Compliance Certification Word None English
HCF-01520 F-01520 Physical Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01523 F-01523 Physician and Physician Assistant Terms of Reimbursement (PDF, 42 KB) PDF None English
DPH F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application WORD None English
OQA-2333 F-62333 Plan Approval Application and Instructions Word None English
OQA-2333 F-62333 Plan Approval Application and Instructions (PDF, 81 KB) PDF None English
DDE-0934AS F-20934AS Plan Recommendation - Spanish (PDF, 15 KB) PDF None Spanish
DDE-0934A F-20934A Plan Recommendation* (PDF, 36 KB) PDF None English
DQA F-00496 Plan Review Code Interpretation Request Word None English
DQA F-00496 Plan Review Code Interpretation Request (PDF, 26 KB) PDF None English
HCF-01525 F-01525 Podiatrist Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01527 F-01527 Portable X-Ray Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-16015 F-16015 Positive Notice Word None English
HCF-16015 F-16015 Positive Notice (PDF, 134 KB) PDF None English
HCF-16015S F-16015S Positive Notice - Spanish (PDF, 46 KB) PDF None Spanish
OQA-2590 F-62590 Post On-Site Review Questionnaire Nurse Aide Training Programs Word None English
OQA-2590 F-62590 Post On-Site Review Questionnaire Nurse Aide Training Programs (PDF, 20 KB) PDF None English
OQA-2579 F-62579 Post Survey Questionnaire Word None English
OQA-2579 F-62579 Post Survey Questionnaire (PDF, 33 KB) PDF None English
DPH F-00036 Power of Attorney for Finance and Property (PDF, 19KB) PDF None English
DPH F-00085 Power of Attorney for Health Care (PDF, 296 KB) PDF Program English
DPH F-00085A Power of Attorney for Health Care - Letter PDF Program English
DES F-00603 PPS (Program Participation System) Core Module Word None English
DMHSAS F-00588 PPS Alcohol and Other Drug Abuse Module Word None English
DMHSAS F-00588a PPS AODA Deskcard (PDF, 32 KB) PDF None English
DES F-00603a PPS Core Deskcard (PDF, 20 KB) PDF None English
DMHSAS F-00596a PPS Mental Health Deskcard (PDF, 29 KB) PDF None English
DMHSAS F-00596 PPS Mental Health Module Word None English
DDE-2191 F-22191 Pre-admission Screen and Resident Review (PASARR) Level 1 Screen Word None English
DDE-2191 F-22191 Pre-admission Screen and Resident Review (PASARR) Level 1 Screen (PDF, 29 KB) PDF None English
HCF-01105 F-01105 Pre-Natal Care Coordination Pregnancy Questionnaire (PDF, 211 KB) PDF None English
HCF-01105H F-01105H Pre-Natal Care Coordination Pregnancy Questionnaire - Hmong (PDF, 197 KB) PDF None Hmong
HCF-01105A F-01105A Pre-Natal Care Coordination Pregnancy Questionnaire Completion Instructions (PDF, 67 KB) PDF None English
HCF-01105S F-01105S Pre-Natal Care Coordination Program Pregnancy Questionnaire - Spanish (PDF, 202 KB) PDF None Spanish
DPH-07484 F-47484 Pre-Review Questionnaire and Application Checklist Word None English
DPH-00335 F-40335 Pre-School Oral Health Preliminary Exam and Prevention Services (PDF, 439 KB) PDF None English
HCF-01529 F-01529 PreNatal Care Coordination Agency Terms of Reimbursement (PDF, 42 KB) PDF None English
DPH-43016 F-43016 Prevent Heart Disease & Stroke Wallet Card Paper Form Center English
DHCAA F-00081A Prior Authorization / Drug Attachment for Suboxone and Buprenorphine Completion Instructions (PDF, 63 KB) PDF None English
DHCAA F-00704 Prior Authorization Committee Public Testimony Registration (PDF, 29 KB) PDF None English
DLTC F-00315C Prior Notice and Consent for Evaluation - Birth to 3 Word None English
DLTC F-00315C Prior Notice and Consent for Evaluation - Birth to 3 (PDF, 18 KB) PDF None English
DLTC F-00315CS Prior Notice and Consent for Evaluation - Birth to 3 - Spanish (PDF, 21 KB) PDF None Spanish
HCF-01502 F-01502 Private Duty Nursing Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01501 F-01501 Private Duty Nursing to Ventilator-Dependent Members Terms of Reimbursement (PDF, 42 KB) PDF None English
DLTC F-00067 PROAct - Program Review Outcome / Activity Person-Centered Field Review Report Word None English
HCF-13033 F-13033 Probate Claims Notice (PDF, 53 KB) PDF None English
DPH F-00553 Professional & Occupational License Application & Affidavit Word None English
DPH F-00553 Professional & Occupational License Application & Affidavit (PDF, 62 KB) PDF None English
DMT-0890A F-80890A Profile Expense / Budget Summary, Profile Funding Summary - Instructions (PDF, 24 KB) PDF None English
DMT-0881 F-80881 Profile ID Request (CARS) Word None English
DMT-0881A F-80881A Profile ID Request (CARS) Instructions Word None English
DPH-07257 F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers Word None English
DLTC F-00565 Program in Partnership Plan - PIPP Word None English
DLTC F-21225 Program Participation System (PPS): B-3 Module System None English
DDE-1225A F-21225A Program Participation System (PPS): B-3 Module Word None English
DDE-1225A F-21225A Program Participation System (PPS): B-3 Module (PDF, 52 KB) PDF None English
DDE-1225AI F-21225Ai Program Participation System (PPS): B-3 Module - Deskcard (PDF, 41 KB) PDF None English
DLTC F-00603i Program Participation System Core Instructions (PDF, 67 KB) PDF None English
DES F-20942i Program Participation System Expense Report for Human Service Programs - Instructions (PDF, 31 KB) PDF None English
EXEC F-22540i Program Participation System Human Services Revenue Report (HSRR) Expenditures by Revenue Source for Human Service Programs – Instructions (PDF, 34 KB) PDF None English
DQA F-00176 Project Proposal Word None English
DQA F-00176 Project Proposal (PDF, 36 KB) PDF None English
DMT-0739 F-80739 Prompt Payment Compliance Attachment Excel None English
DMT-0739A F-80739A Prompt Payment Compliance Instructions Word None English
DPH-04771D F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels Word None English
DPH-04771D F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels (PDF, 145 KB) PDF None English
DPH-04771C F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels Word None English
DPH-04771C F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels (PDF, 242 KB) PDF None English
HCF-16026 F-16026 Prosecution Diversion Agreement (PDF, 251 KB) PDF None English
DMT-0806 F-80806 Purchase Requisition Word None English
DMT-0806I F-80806i Purchase Requisition Instructions Word None English
HCF-16011 F-16011 Quality Assurance (QA) Sample Check List (PDF, 226 KB) PDF None English
DQA F-00740 Quality Improvement Event Analysis Summary and Suggested Event Analysis Process (PDF, 46 KB) Restricted None English
OQA-9311 F-69311 Quality of Life Assessment - Family Interview CMS-806C Paper Form Center English
OQA-9310 F-69310 Quality of Life Assessment - Group Interview CMS-806B Paper Form Center English
OQA-9309 F-69309 Quality of Life Assessment - Resident Interview CMS-806A Paper Form Center English
DLTC F-00478 Quality of Life Survey - Money Follows the Person (MFP) Word None English
DLTC F-00478 Quality of Life Survey - Money Follows the Person (MFP) (PDF, 59 KB) PDF None English
DPH-40089 F-40089 Receipt For Confiscated WIC Checks Word Program English
DMT-0900 F-80900 Receivables Annual Report Excel None English
DMT-0900A F-80900A Receivables Quarterly Report Excel None English
DDE-0946 F-20946 Recertification Assurance--COP-W / CIP II Word None English
DDE-0585 F-20585 Recertification for Wisconsin Medicaid Katie Beckett Program Word None English
DDE-0585I F-20585i Recertification for Wisconsin Medicaid Katie Beckett Program, Instructions (PDF, 21 KB) PDF None English
DDE-0585C F-20585C Recertification for Wisconsin Medicaid, Katie Beckett Program - Short Form Word None English
DDE-0585CI F-20585ci Recertification for Wisconsin Medicaid, Katie Beckett Program - Short Form Instructions (PDF, 20KB) PDF None English
DPH-45019 F-45019 Reciprocity Privileges Checklist (PDF, 92 KB) PDF None English
DPH-05024S F-05024IS Reconocimento Voluntario de la Paternidad en Wisconsin - Instrucciones en Español Paper Program Spanish
DPH-07208 F-47208 Recreational / Educaional Camp Inspection Report Paper Form Center English
DDE-2469 F-22469 Referral For OBVI Services Word None English
DPH-04192S F-44192S Registro de Inmunizaciones para Guardería Infantil (Day Care Immunization Record) (PDF, 468 KB) PDF None Spanish
HCF-01531 F-01531 Rehabilitation Agency Terms of Reimbursement (PDF, 42 KB) PDF None English
EXEC F-83265 Rehabilitation Review Appeals Report Word Program English
EXEC F-83265A Rehabilitation Review Appeals Report-Instructions Word Program English
EXEC F-83263 Rehabilitation Review Application and Instructions (PDF, 114 KB) PDF None English
EXEC F-83264 Rehabilitation Review Panel Decision Report Word Program English
EXEC F-83264A Rehabilitation Review Panel Decision Report - Instructions Word Program English
DPH-42026 F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program (PDF, 28 KB) PDF None English
DHCAA F-00233 Renewal Summary Letter Word None English
DHCAA F-00233H Renewal Summary Letter (Hmong) Word None Hmong
DHCAA F-00233S Renewal Summary Letter (Spanish) Word None Spanish
DQA F-62369S Renuncia a Los Servicios de Hospicio o Cuidado de Salud en el Hogar de un Residente Con Enfermedad Terminal Word None Spanish
DQA F-62369S Renuncia a Los Servicios de Hospicio o Cuidado de Salud en el Hogar de un Residente Con Enfermedad Terminal (PDF, 13 KB) PDF None Spanish
DPH-05035 F-05035 Report Change Name, Sex Birth Certificate Surgical Procedure Word Program English
DPH-05045 F-05045 Report for Final Disposition Paper Program English
OIG F-00577 Report Fraud ASP None English
DPH-05022 F-05022 Report of Adoption Paper Program English
DPH-05022F F-05022F Report of Adoption - Child Born In A Foreign Country Paper Program English
DPH-05022T F-05022T Report of Adoption - Tribal Paper Program English
DPH-05032 F-05032 Report of Birth Certificate Changes After Surrogate Birth (PDF, 42 KB) PDF Program English
DPH-05027A F-05027A Report of Citizenship Paper Program English
DPH-07228 F-47228 Report of Enforcement Methods Paper Program English
DPH-07225 F-47225 Report of Enforcement Methods (Part 1) Paper Program English
DPH-07226 F-47226 Report of Enforcement Methods (Part II) Paper Program English
OQA-2164 F-62164 Report of Hours Worked - Licensed Practical Nurse / Day Word None English
OQA 2164 F-62164 Report of Hours Worked - Licensed Practical Nurse / Day (PDF, 21 KB) PDF None English
OQA-2165 F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening Word None English
OQA 2165 F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening (PDF, 22 KB) PDF None English
OQA-2166 F-62166 Report of Hours Worked - Licensed Practical Nurse / Night Word None English
OQA 2166 F-62166 Report of Hours Worked - Licensed Practical Nurse / Night (PDF, 22 KB) PDF None English
OQA-2024 F-62024 Report of Hours Worked - Nurse Aide / Day Word None English
OQA 2024 F-62024 Report of Hours Worked - Nurse Aide / Day (PDF, 20 KB) PDF None English
OQA-2026 F-62026 Report of Hours Worked - Nurse Aide / Evening Word None English
OQA 2026 F-62026 Report of Hours Worked - Nurse Aide / Evening (PDF, 20 KB) PDF None English
OQA-2028 F-62028 Report of Hours Worked - Nurse Aide / Night Word None English
OQA 2028 F-62028 Report of Hours Worked - Nurse Aide / Night (PDF, 20 KB) PDF None English
OQA-62440 F-62440 Report of Hours Worked - Other Direct Care Nurse Aide / Day Word None English
DQA F-62440 Report of Hours Worked - Other Direct Care Nurse Aide / Day (PDF, 20 KB) PDF None English
OQA-62441 F-62441 Report of Hours Worked - Other Direct Care Nurse Aide / Evening Word None English
DQA F-62441 Report of Hours Worked - Other Direct Care Nurse Aide / Evening (PDF, 20 KB) PDF None English
OQA-62442 F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night Word None English
DQA F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night (PDF, 20 KB) PDF None English
OQA-2023 F-62023 Report of Hours Worked - Registered Nurse / Day Word None English
OQA 2023 F-62023 Report of Hours Worked - Registered Nurse / Day (PDF, 171 KB) PDF None English
OQA-2025 F-62025 Report of Hours Worked - Registered Nurse / Evening Word None English
OQA 2025 F-62025 Report of Hours Worked - Registered Nurse / Evening (PDF, 20 KB) PDF None English
OQA-2027 F-62027 Report of Hours Worked - Registered Nurse / Night Word None English
OQA 2027 F-62027 Report of Hours Worked - Registered Nurse / Night (PDF, 20 KB) PDF None English
DPH-05021 F-05021 Report of Legal Name Change Paper Form Center English
DPH F-05021C Report of Legal Name Change - Confidential Paper User English
DPH-05021T F-05021T Report of Legal Name Change - Tribal Paper None English
DPH-05027B F-05027B Report of Naturalization Paper Program English
DDE-2433 F-22433 Request for a Hearing, Wisconsin Birth to 3 Program Word None English
DDE-2433 F-22433 Request for a Hearing, Wisconsin Birth to 3 Program (PDF, 12 KB) PDF None English
DDE-2433 F-22433S Request for a Hearing, Wisconsin Birth to 3 Program - Spanish Word None Spanish
DDE-2433 F-22433S Request for a Hearing, Wisconsin Birth to 3 Program - Spanish (PDF, 17 KB) PDF None English
DLTC F-00236 Request for a State Fair Hearing Word None English
DLTC F-00236A Request for a State Fair Hearing - ADRC Word None English
DLTC F-00236B Request for a State Fair Hearing - IRIS Word None English
DQA F-00386 Request for Americans with Disability Act (ADA) Accommodation Word None English
DQA F-00386 Request for Americans with Disability Act (ADA) Accommodation (PDF, 21 KB) PDF None English
OQA-2589 F-62589 Request for Approval to use Telehealth Word None English
OQA-2589 F-62589 Request for Approval to use Telehealth (PDF, 33 KB) PDF None English
DMHSAS F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model Word None English
DMHSAS F-00198 Request for Clinical Case Consultation Application Word None English
DDE-0691 F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications Word None English
DDE-0691 F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications (PDF, 14 KB) PDF None English
DDE-5527 F-25527 Request for Increased Contract Allocation Word None English
DDE-0448 F-20448 Request for Medicaid Administrative Funds Word None English
OQA-2457 F-62457 Request for Permission to Start Footings, Foundation and/or Demolition Word None English
OQA-2457 F-62457 Request for Permission to Start Footings, Foundation and/or Demolition (PDF, 34 KB) PDF None English
DPH-44018 F-44018 Request for Repairs (PDF, 27 KB) PDF None English
DHCAA F-00330 Request for Replacement FoodShare Benefits (PDF, 28 KB) PDF None English
DDE-0572 F-20572 Request for State Public Funding for Non-Residents* Word None English
OQA-2256 F-62256 Request for Title XIX Care Level Determination Word None English
OQA-2256 F-62256 Request for Title XIX Care Level Determination (PDF, 28 KB) PDF None English
OQA-2256A F-62256A Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client / Residents Word None English
OQA-2256A F-62256A Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client / Residents (PDF, 35 KB) PDF None English
OQA-2608 F-62608 Request for Use of Medical Restraints Word None English
OQA-2608 F-62608 Request for Use of Medical Restraints (PDF, 27 KB) PDF None English
DLTC F-00926A Request for Use of Medical Restraints – CLTS Word None English
DLTC F-00926A Request for Use of Medical Restraints – CLTS (PDF, 51 KB) PDF None English
DLTC F-00926 Request for Use of Restraints, Isolation, or Protective Equipment - CLTS Word None English
DLTC F-00926 Request for Use of Restraints, Isolation, or Protective Equipment - CLTS (PDF, 49 KB) PDF None English
OQA-2607 F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan Word None English
OQA-2607 F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan (PDF, 29 KB) PDF None English
DPH F-00569 Request for Waiver of Administrative Rule for Licensure Word None English
DLTC F-00054 Request for Waiver of Education / Experience Requirements (ADRC) Word None English
DLTC F-00054E Request for Waiver of Education / Experience Requirements - TADRS Word None English
DLTC F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and MCO or ADRC and Care Management Staff Word None English
DLTC F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC Word None English
DDE-2539 F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate (PDF, 96 KB) PDF None English
DLTC F-00054D Request for Waiver of the .5 Full-Time Equivalent Requirement for ADRC Staff Word None English
DPH-05029 F-05029 Request To Withdraw Voluntary Paternity Acknowledgement (PDF, 42 KB) PDF Program English
  F-00923 Reschedule Lead (PB) Certification Exam (PDF, 90 KB) PDF None English
HFS-0021 F-82021 Researcher's Request for Confidential Records or Human Subjects Research (PDF, 14 KB) PDF None English
OQA-2030 F-62030 Resident Census Word None English
OQA 2030 F-62030 Resident Census (PDF, 27 KB) PDF None English
OQA-9260 F-69260 Resident Census and Conditions of Residents CMS-672 Paper Form Center English
OQA-2373 F-62373 Resident Evacuation Assessment Word None English
OQA-2373 F-62373 Resident Evacuation Assessment (PDF, 38 KB) PDF None English
OQA-9308 F-69308 Resident Review Worksheet CMS-805 Paper Form Center English
OQA-2380 F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application Word None English
OQA-2380 F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application (PDF, 33 KB) PDF None English
OQA-2528 F-62528 Residential Care Apartment Complex Initial Certification of Registration Checklist Word None English
OQA-2528 F-62528 Residential Care Apartment Complex Initial Certification of Registration Checklist (PDF, 16 KB) PDF None English
OQA-2381 F-62381 Residential Care Apartment Complex Regulations Compliance Statement Word None English
OQA-2381 F-62381 Residential Care Apartment Complex Regulations Compliance Statement (PDF, 54 KB) PDF None 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-00108 F-40108 Retail Vendor Application Amendment Women, Infant, and Children (WIC) (PDF, 261 KB) PDF None English
DDE-1189 F-21189 Rights of Detention Word None English
DMHSAS F-21189S Rights of Detention Word None Spanish
DQA F-62601 Rights of Home Health Agency Patients Word None English
OQA-2601 F-62601 Rights of Home Health Agency Patients (PDF, 26 KB) PDF None English
OQA-2601S F-62601S Rights of Home Health Agency Patients - Spanish (PDF, 21 KB) PDF None Spanish
DLTC F-00010 Risk Agreement - Participant Word None English
OQA-9305 F-69305 Roster / Sample Matrix CMS-802 Paper Form Center English
HCF-01533 F-01533 Rural Health Clinic Terms of Reimbursement (PDF, 44 KB) PDF None English
DPH-45029 F-45029 School Food Safety Program Inspection Report Paper Form Center English
DPH-04002 F-04002 School Report to Local Health Department (PDF, 320 KB) PDF None English
DPH-04212 F-44212 School Report to the District Attorney (PDF, 14 KB) PDF Program English
HCF-01535 F-01535 School-Based Services Terms of Reimbursement (PDF, 41 KB) PDF None English
DMHSAS F-20389B Screening, Brief Intervention and Referral to Treatment (SBIRT) - Agency Performance Report for SBIRT Services Word None English
DMHSAS F-20389A Screening, Brief Intervention and Referral to Treatment - Treatment Program Performance Report Word None English
DMT-1009a F-81009A Security Incident Report Word None English
OQA-0309 F-60309 Self Supervision Evaluation and Waiver Request Word None English
OQA-0309 F-60309 Self Supervision Evaluation and Waiver Request (PDF, 31 KB) PDF None English
DLTC F-00558 Self-Assessment Summary Word None English
DLTC F-00543A Self-Assessment/On-Site File Review Checklist Word None English
DLTC F-00543A Self-Assessment/On-Site File Review Checklist (PDF, 63 KB) PDF None English
DHCAA F-00107 Self-Employment Income Report (PDF, 47 KB) PDF None English
DHCAA F-00107W Self-Employment Income Report (Worksheet) (PDF, 32 KB) PDF None English
DHCAA F-00219 Self-Employment Income Report - Farmer (PDF, 74 KB) PDF None English
DHCAA F-00219W Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) PDF None English
DHCAA F-00219H Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) PDF None Hmong
DHCAA F-00219S Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) PDF None Spanish
DHCAA F-00107H Self-Employment Income Report - Hmong (PDF, 51 KB) PDF None Hmong
DHCAA F-00107S Self-Employment Income Report - Spanish (PDF, 52 KB) PDF None Spanish
HCF-16034 F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) PDF None English
HCF-16036 F-16036 Self-Employment Income Worksheet - Partnership (PDF, 27 KB) PDF None English
HCF-16037 F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) PDF None English
HCF-16037 F-16037A Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 25 KB) PDF None English
HCF-16035 F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) PDF None English
DPH F-00005 Senior FMNP Agency Application to Participate Word None English
HCF-10076 F-10076 SeniorCare Application (PDF, 179 KB) Paper Form Center English
HCF-10080 F-10080 SeniorCare Authorization of Representative (PDF, 486 KB) PDF None English
HCF-10076A F-10076A SeniorCare Instructions for Application Form (PDF, 71 KB) Paper Form Center English
HCF-10076AH F-10076AH SeniorCare Instructions for Application Form - Hmong (PDF, 128 KB) PDF None Hmong
HCF-10076AS F-10076AS SeniorCare Instructions for Application Form - Spanish (PDF, 124 KB) PDF None Spanish
DES F-00166 Service Delivery / Employment Discrimination Complaint Word None English
DES F-00166AL Service Delivery / Employment Discrimination Complaint - Albanian (PDF, 51 KB) PDF None Albanian
DES F-00166AR Service Delivery / Employment Discrimination Complaint - Arabic (PDF, 111 KB) PDF None Arabic
DES F-00166BU Service Delivery / Employment Discrimination Complaint - Burmese (PDF, 108 KB) PDF None Burmese
DES F-00166CC Service Delivery / Employment Discrimination Complaint - Cantonese (PDF, 250 KB) PDF None Cantonese
DES F-00166FA Service Delivery / Employment Discrimination Complaint - Farsi (PDF, 105 KB) PDF None Farsi
DES F-00166H Service Delivery / Employment Discrimination Complaint - Hmong (PDF, 59 KB) PDF None Hmong
DES F-00166KH Service Delivery / Employment Discrimination Complaint - Khmer (PDF, 114 KB) PDF None Khmer
DES F-00166KR Service Delivery / Employment Discrimination Complaint - Korean (PDF, 239 KB) PDF None Korean
DES F-00166L Service Delivery / Employment Discrimination Complaint - Laotian (PDF, 268 KB) PDF None Laotian
DES F-00166CM Service Delivery / Employment Discrimination Complaint - Madarin (PDF, 335 KB) PDF None Mandarin
DES F-00166R Service Delivery / Employment Discrimination Complaint - Russian (PDF, 119 KB) PDF None Russian
DES F-00166SE Service Delivery / Employment Discrimination Complaint - Serbian (PDF, 102 KB) PDF None Serbian
DES F-00166SO Service Delivery / Employment Discrimination Complaint - Somali (PDF, 51 KB) PDF None Somali
DES F-00166S Service Delivery / Employment Discrimination Complaint - Spanish (PDF, 52 KB) PDF None Spanish
DES F-00166V Service Delivery / Employment Discrimination Complaint - Vietnamese (PDF, 121 KB) PDF None Vietnamese
DPH F-00114 Service Director License Proxy for Individuals Word None English
DPH F-00114 Service Director License Proxy for Individuals (PDF, 120 KB) PDF None English
DPH-04243 F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report Word Form Center English
OQA-2370 F-62370 Significant Change in Health Screening Instrument Model Form Word None English
OQA-2370 F-62370 Significant Change in Health Screening Instrument Model Form (PDF, 55 KB) PDF None English
DPH-07020 F-47020 Sink Requirements Paper Program English
EXEC F-83292 Small Business Concern Feedback Word None English
HCF-16022 F-16022 Social Security Number Referral (PDF, 61 KB) PDF None English
HCF-16022H F-16022H Social Security Number Referral - Hmong (PDF, 28 KB) PDF None Hmong
HCF-16022S F-16022S Social Security Number Referral - Spanish (PDF, 26 KB) PDF None Spanish
DMT-0857 F-80857 Special CARS Run request Word None English
DHCAA F-00885 Specialized Medical Vehicle Insurance Documentation Checklist Word None English
DHCAA F-00885 Specialized Medical Vehicle Insurance Documentation Checklist (PDF, 48 KB) PDF None English
HCF-01537 F-01537 Specialized Medical Vehicle Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01104 F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster Excel None English
HCF-01084 F-01084 Speech - Language Pathology Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
DDE-0812 F-20812 SSI-E Natural Residential Setting Application Checklist Word None English
DDE-0812 F-20812 SSI-E Natural Residential Setting Application Checklist (PDF, 73 KB) PDF None English
DMT-0905 F-80905 State Instant Deposit Program Enrollment (PDF, 17 KB) PDF None English
DMT-0905T F-80905T State Instant Deposit Program Enrollment - Tribes / Great Lakes Tribal Council Word None English
DMT-0905T F-80905T State Instant Deposit Program Enrollment - Tribes / Great Lakes Tribal Council (PDF, 19 KB) PDF None English
DPH-07013 F-47013 State of Wisconsin Permit Application Word None English
DPH-07018 F-47018 State of Wisconsin Permit Application to Operate a Mobile Restaurant / Mobile Service Base Word Form Center English
DHCAA F-00100 State Vital Records Cover Letter Word None English
HCF-10161 F-10161 Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) PDF None English
HCF-10154 F-10154 Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) PDF None English
HCF-10154H F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) PDF None Hmong
HCF-10154R F-10154R Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) PDF None Russian
HCF-10154S F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) PDF None Spanish
HCF-10175 F-10175 Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) PDF None English
DDE-5177 F-25177 Statement of Probable Cause and Detention and Petition for Revocation Word None English
DDE-5177 F-25177 Statement of Probable Cause and Detention and Petition for Revocation (PDF, 14 KB) PDF None English
DHCAA F-00685 Statement of Tribal Affiliation (PDF, 24 KB) PDF None English
DDE-0935 F-20935 Status Report to Court for Plan Compliance (PDF, 41 KB) PDF None English
DPH-40065 F-40065 Storage Facility Review Monitoring Report Word None English
DMT-0762 F-80762 Store Inventory Reconciliation Worksheet Excel None English
HCF-16023 F-16023 Striker Evaluation (PDF, 395 KB) PDF None English
HCF-16031 F-16031 Student Aid and Expense Worksheet (PDF, 256 KB) PDF None English
HCF-16021 F-16021 Student Financial Report (PDF, 194 KB) PDF None English
DPH-04020 F-04020 Student Immunization Record - This form is intended for Schools Paper Form Center English
DPH-04020L F-04020L Student Immunization Record, Long (PDF, 303 KB) PDF Form Center English
DPH-04020LH F-04020LH Student Immunization Record, Long - Hmong (PDF, 84 KB) PDF Form Center Hmong
DPH-04020LS F-04020LS Student Immunization Record, Long - Spanish (PDF, 50 KB) PDF Form Center Spanish
DQA F-62696 Student Nurse/Graduate Nurse Verification Word None English
DQA F-62696 Student Nurse/Graduate Nurse Verification (PDF, 20 KB) PDF None English
DMHSAS F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval Word None English
DDE-2567A F-22567A Substance Abuse Prevention and Treatment Block Grant Annual Expenditure Report Excel None English
DDE-2567 F-22567 Substance Abuse Prevention and Treatment Block Grant Annual Report Word None English
DDE-1088 F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request Word None English
DMT-0015 F-80015 Summary of Depository Funds Annual Report Excel None English
DHCAA F-00098 Summary of Information Letter Word None English
DPH-07222 F-47222 Summary Suspension Paper Program English
DPH F-00653b Surgeon Data Import Training Excel None English
DQA F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey Word None English
DQA F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey (PDF, 26 KB) PDF None English
OQA-9312 F-69312 Surveyor Notes Worksheet CMS-807 Paper Form Center English
DPH-45036 F-45036 Swimming Pool and Water Attraction Death, Injury and Ilness Report (PDF, 27 KB) PDF Program English
DPH F-00018 Swimming Pool and Water Attraction Fecal Incident Report (PDF, 21 KB) PDF None English
DPH-07205 F-47205 Swimming Pool Inspection Report (PDF, 929 KB) PDF Form Center English
DPH-07454 F-47454 Tattoo and Body Piercing Inspection Report (PDF, 2.9 MB) PDF Form Center English
DPH F-00458 TDAP Cocooning Report (PDF, 17 KB) PDF None English
DDE-0397 F-20397 Telecommunications Assistance Program (TAP) Voucher Paper Program English
HCF-10119 F-10119 Temporary Enrollment For Family Planning Only Services Paper Form Center English
HCF-10119A F-10119A Temporary Enrollment For Family Planning Only Services Instructions (PDF, 99 KB) PDF None English
DPH F-00658 Temporary Food Service Permit Application Word None English
DPH-07223A F-47223A Temporary Or Final Order Tag Paper Program English
DPH-45004 F-45004 Temporary Restaurant Inspection Report Paper Form Center English
DPH-40066 F-40066 The Emergency Food Assistance Program (TEFAP) Word None English
DPH-40063 F-40063 The Emergency Food Assistance Program (TEFAP) Commodities Complaint Word None English
DPH-40061 F-40061 The Emergency Food Assistance Program (TEFAP) Commodities Inventory Word None English
DPH-40059H F-40059H The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Hmong Word None Hmong
DPH-40059 F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Monthly Word None English
DPH-40059 F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Monthly (PDF, 32 KB) PDF None English
DPH-40059R F-40059R The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Russian Word None Russian
DPH-40059S F-40059S The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Spanish Word None Spanish
DPH-40059S F-40059S The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Spanish (PDF, 40 KB) PDF None Spanish
DPH-40060A F-40060A The Emergency Food Assistance Program Commodities at Pantry, Soup Kitchen, and Shelter Word Program English
DPH-40060 F-40060 The Emergency Food Assistance Program Commodities Inventory Report Word Program English
DPH-40062 F-40062 The Emergency Food Assistance Program TEFAP and CSFP Commodity Loss Report Word None English
DLTC F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information Word None English
DPH F-00336 Tickborne Rickettsial Disease Case Report (PDF, 530 KB) PDF None English
OQA-2194 F-62194 Title XIX Recipient Termination Notice Word None English
OQA-2194 F-62194 Title XIX Recipient Termination Notice (PDF, 55 KB) PDF None English
DES F-20942a Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet (PDF, 23 KB) PDF None English
DPH-45010D F-45010D Training Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) Word None English
DPH-45010D F-45010D Training Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) (PDF, 100 KB) PDF None English
DPH-45010A F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) Word None English
DPH-45010A F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) (PDF, 299 KB) PDF None English
DPH-45010B F-45010B Training, Experience and Preceptor Attestation - B (Authorized User -Written Directive Not Required) Word None English
DPH-45010B F-45010B Training, Experience and Preceptor Attestation - B (Authorized User -Written Directive Not Required) (PDF, 1 MB) PDF None English
DPH-45010C F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) Word None English
DPH-45010C F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) (PDF, 179 KB) PDF None English
DPH-45010E F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units) Word None English
DPH-45010E F-45010E Training, Experience and Preceptor Attestation - E (Authorized User Of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units) (PDF, 69 KB) PDF None English
DPH-45010F F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) Word None English
DPH-45010F F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) (PDF, 45 KB) PDF None English
DPH-45010G F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) Word None English
DPH-45010G F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) (PDF, 54 KB) PDF None English
DDE-2605 F-22605 Transfer for Protective Placement Word None English
DDE-2605 F-22605 Transfer for Protective Placement (PDF, 11 KB) PDF None English
DPH-40064 F-40064 Transfer of The Emergency Food Assistance Program (TEFAP) Commodities between EFO's Word None English
DLTC F-00315B Transition Written Prior Notice - Birth to 3 Word None English
DLTC F-00315B Transition Written Prior Notice - Birth to 3 (PDF, 51 KB) PDF None English
DLTC F-00315BS Transition Written Prior Notice - Birth to 3 - Spanish (PDF, 18 KB) PDF None Spanish
DPH-07479 F-47479 Trauma Care Facility Classification Application Word None English
DPH-07479 F-47479 Trauma Care Facility Classification Application (PDF, 2.1 MB) PDF None English
DES F-80190 Travel Reimbursement Request Non-State Employee Excel None English
DMT-0190 F-80190 Travel Reimbursement Request Non-State Employee (PDF, 44 KB) PDF None English
DES F-80190A Travel Reimbursement Request State Employee Excel None English
DLTC F-00576A Tribal Aging and Disability Resource Specialist (TADRC) Annual Budget Excel None English
DLTC F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application Word None English
DPH-42001 F-42001 Tuberculosis Suspect Case Data (PDF, 226 KB) PDF None English
DDE-9324 F-29324 Uniform Cost Sharing Plan (PDF, 11 KB) PDF None English
DHCAA F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) PDF None English
DES F-00044 User Agreement for System Access Word None English
DPH-04702 F-44702 Vaccine Administration Record (PDF, 41 KB) PDF Form Center English
DPH-04702S F-44702S Vaccine Administration Record - Spanish (PDF, 46 KB) PDF Form Center Spanish
DPH-42023 F-42023 Vaccine Celsius Temperature Log (PDF, 2.4 MB) PDF None English
DPH-42024 F-42024 Vaccine Fahrenheit Temperature Log (PDF, 2.4 MB) PDF None English
DPH-42000 F-42000 Vaccine Order (PDF, 34 KB) PDF None English
DLTC F-00076 Variance Request - Wait List Word None English
DLTC F-00076 Variance Request - Wait List (PDF, 24 KB) PDF None English
DDE-1056 F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution Word None English
DDE-1056 F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution (PDF, 20 KB) PDF None English
DDE-1059 F-21059 Variance Request for Institutional Respite Word None English
DDE-1059 F-21059 Variance Request for Institutional Respite (PDF, 14 KB) PDF None English
DPH-07015 F-47015 Vending Inspection Report Paper Program English
DPH-45040 F-45040 Vending Machine Information Record Word None English
DPH-45040 F-45040 Vending Machine Information Record (PDF, 26 KB) PDF None English
DPH-04322 F-44322 Vendor / Participant Complaint Women, Infant, and Children (WIC) (PDF, 88 KB) PDF None English
DPH-04324 F-44324 Vendor Site Visit Paper Program English
DMT-0112 F-80112 Vendor Validation Word None English
DMT-0112A F-80112A Vendor Validation Instructions Word None English
DPH-40058 F-40058 Verification of Transfer of USDA Commodities Word Program English
HCF-10162 F-10162 Verification of Veterans Benefits (PDF, 53 KB) PDF None English
DPH-05283 F-05283 Veterans Application Restricted Program English
DPH-04292 F-44292 VIP Immunization Record 6 X 4 Paper Form Center English
DLTC F-00037F Virtual PACE Program - Listserv Sign-Up HTML None English
DPH-44005 F-44005 Visual Inspection of Registered Lead-Safe Property (PDF, 15 KB) PDF None English
DPH-05191 F-05191 Vital Records Fee Schedule--Now numbered P-05191 Paper Form Center English
DMHSAS F-00335 Voluntary Agreement for Respite Care and Crisis Services Word None English
DPH-05024 F-05024 Voluntary Paternity Acknowledgement Paper Program English
DPH-05024 F-05024S Voluntary Paternity Acknowledgement - Spanish Paper Program Spanish
HCF-16039 F-16039 Waiver of Administrative Disqualification Hearing (PDF, 141 KB) PDF None English
HCF-16039S F-16039S Waiver of Administrative Disqualification Hearing - Spanish (PDF, 116 KB) PDF None Spanish
OQA-2369 F-62369 Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF) Word None English
OQA-2369 F-62369 Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF) (PDF, 12 KB) PDF None English
EXEC F-00945 Waiver Request Word None English
DQA F-00016 Wall Closure Inspection Checklist Word None English
DQA F-00016 Wall Closure Inspection Checklist (PDF, 17 KB) PDF None English
DPH-42002 F-42002 Warning: Do Not Unplug Refrigerator - Label Paper Program English
DPH-45031 F-45031 Waterslide Inspection Report Paper Form Center English
DLTC F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers Word None English
DDE-1192A F-21192A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers Word None English
DDE-1192 F-21192 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies Word None English
DLTC F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies Word None English
DLTC F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports Word None English
DDE-1192B F-21192B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports Word None English
DPH-04158 F-44158 WIC Application Brochure/Postcard Paper Form Center English
DPH-04158H F-44158H WIC Application Brochure/Postcard - Spanish Paper Form Center Hmong
DPH-04158S F-44158S WIC Application Brochure/Postcard - Spanish Paper Form Center Spanish
HFS-0009II F-82009II WIC Confidential Information Release Authorization (PDF, 52 KB) PDF Form Center English
HFS-0009IIH F-82009IIH WIC Confidential Information Release Authorization - Hmong (PDF, 26 KB) PDF Form Center Hmong
HFS-0009IIS F-82009IIS WIC Confidential Information Release Authorization - Spanish (PDF, 94 KB) PDF Form Center Spanish
DPH-04757 F-44757 WIC Farmer's Market Contract For Farmers Paper Program English
DPH-04755 F-44755 WIC Farmers' Market Nutrition Program Word Program English
DPH F-44024D WIC Formula and Medical Nutritional Prescriptions / Clinical Data Infants (PDF, 51 KB) PDF None English
DPH-04160L F-44160L WIC ID Folder Paper Form Center English
DPH-04160LS F-44160LS WIC ID Folder - Spanish Paper Form Center Spanish
DPH-40076 F-40076 WIC Income Statement (PDF, 85 KB) PDF Form Center English
DPH-40076S F-40076S WIC Income Statement - Spanish (PDF, 103 KB) PDF Form Center Spanish
DPH-04160A F-44160A WIC Plastic Cover for WIC ID Folder Paper Form Center English
DPH-04024B F-44024B WIC Prescriptions / Clinical Data Children (PDF, 35 KB) PDF None English
DPH-04024A F-44024A WIC Prescriptions / Clinical Data Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women (PDF, 30 KB) PDF None English
DPH-40052A F-40052A WIC Program Breast Pump Order Request Word None English
DPH-40052A F-40052A WIC Program Breast Pump Order Request (PDF, 116 KB) PDF None English
DPH-40082 F-40082 WIC Program Civil Rights Discrimination Complaint (PDF, 27 KB) PDF None English
DPH-40082S F-40082S WIC Program Civil Rights Discrimination Complaint - Spanish (PDF, 26 KB) PDF None Spanish
DPH-40094 F-40094 WIC Program Lost or Stolen Check Replacement Agreement Word None English
DPH-40094 F-40094 WIC Program Lost or Stolen Check Replacement Agreement (PDF, 88 KB) PDF None English
DPH F-40094H WIC Program Lost or Stolen Check Replacement Agreement - Hmong Word None Hmong
DPH-40094 F-40094H WIC Program Lost or Stolen Check Replacement Agreement - Hmong (DPF, 20 KB) PDF None Hmong
DPH F-40094S WIC Program Lost or Stolen Check Replacement Agreement - Spanish Word None Spanish
DPH-40094 F-40094S WIC Program Lost or Stolen Check Replacement Agreement - Spanish (PDF, 19 KB) PDF None Spanish
DPH-40085 F-40085 WIC Program Notice of Ineligibility (PDF, 48 KB) PDF None English
DPH-40085S F-40085S WIC Program Notice of Ineligibility - Spanish (PDF, 58 KB) PDF None Spanish
DPH-40096 F-40096 WIC Program Repayment Agreement (PDF, 65 KB) PDF None English
DPH F-40096H WIC Program Repayment Agreement - Hmong (PDF, 17 KB) PDF None Hmong
DPH F-40096S WIC Program Repayment Agreement - Spanish (PDF, 17 KB) PDF None Spanish
DPH-40095 F-40095 WIC Program Repayment Agreement With Proxy Designation (PDF, 111 KB) PDF None English
DPH F-40095H WIC Program Repayment Agreement With Proxy Designation - Hmong (PDF, 17 KB) PDF None Hmong
DPH F-40095S WIC Program Repayment Agreement With Proxy Designation - Spanish (PDF, 17 KB) PDF None Spanish
DPH-40104 F-40104 WIC Retail Vendor Annual Food Sales Survey (PDF, 72 KB) PDF None English
DPH-04161 F-44161 WIC Rights and Responsibilities (PDF, 35 KB) PDF Form Center English
DPH-04161H F-44161H WIC Rights and Responsibilities - Hmong (PDF, 30 KB) PDF Form Center Hmong
DPH-04161S F-44161S WIC Rights and Responsibilities - Spanish (PDF, 42 KB) PDF Form Center Spanish
DPH-04323 F-44323 WIC Stock Price Survey - Formula and Liquid Nutrition Products(PDF, 15 KB) PDF None English
DPH F-44444 WIC Vendor Supply Request Word None English
DPH-04727 F-44727 WIC Vendor Training Proof Paper Form Center English
HCF-01185 F-01185 Wisconsin Adult Cystic Fibrosis Program Application (PDF, 38 KB) PDF None English
HCF-01185A F-01185A Wisconsin Adult Cystic Fibrosis Program Application Instructions (PDF, 39 KB) PDF None English
HCF-01188 F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement (PDF, 46 KB) PDF None English
HCF-01196 F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01188A F-01188A Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Instructions (PDF, 39 KB) PDF None English
HCF-01144 F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification (PDF, 30 KB) PDF None English
DLTC F-00366 Wisconsin Adult Long Term Care Functional Screen (PDF, 132 KB) PDF None English
DPH-42027 F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment (PDF, 52 KB) PDF None English
DLTC F-00915 Wisconsin Birth to 3 Program - Data Discussion Evaluation Word None English
DLTC F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance Word None English
HCF-13154 F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request (PDF, 172 KB) PDF None English
HCF-13155 F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request (PDF, 148 KB) PDF None English
HCF-13156 F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request (PDF, 163 KB) PDF None English
HCF-13157 F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request (PDF, 149 KB) PDF None English
HCF-13153 F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure (PDF, 168 KB) PDF None English
HCF-13158 F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint (PDF, 168 KB) PDF None English
HCF-13159 F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request (PDF, 151 KB) PDF None English
HCF-13160 F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization (PDF, 163 KB) PDF None English
HCF-01541 F-01541 Wisconsin Chronic Disease Program Provider Agreement and Acknowledgement of Terms of Participation (Standard for Individual and Clinic / Group / Agency Providers) PDF None English
HCF-01540 F-01540 Wisconsin Chronic Disease Program Provider Application and Instructions PDF None English
HCF-01146 F-01146 Wisconsin Chronic Disease Program Provider Data Sheet (PDF, 45 KB) PDF None English
HCF-01539 F-01539 Wisconsin Chronic Disease Program Provider Enrollment (PDF, 354 KB) PDF None English
HCF-01186 F-01186 Wisconsin Chronic Renal Disease Program Application (PDF, 55 KB) PDF None English
HCF-01186A F-01186A Wisconsin Chronic Renal Disease Program Application Instructions (PDF, 39 KB) PDF None English
HCF-01058 F-01058 Wisconsin Chronic Renal Disease Program Drug Benefits Important Notice (PDF, 40 KB) PDF None English
HCF-01189 F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement (PDF, 50 KB) PDF None English
HCF-01194 F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01189A F-01189A Wisconsin Chronic Renal Disease Program Financial Need Statement Instructions (PDF, 40 KB) PDF None English
HCF-01143 F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification (PDF, 32 KB) PDF None English
DES F-00754 Wisconsin Civil Service Request for Examination Accommodations Word None English
DES F-00754 Wisconsin Civil Service Request for Examination Accommodations (PDF, 27 KB) PDF None English
DHCAA F-00154 Wisconsin Consultative Examination Inquiry Word None English
DMHSAS F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance Word None English
DPH-04824 F-44824 Wisconsin Day Care Assessment Paper Program English
DPH F-00123 Wisconsin Declaration of Domestic Partnership Application (PDF, 102 KB) PDF None English
DPH F-00123S Wisconsin Declaration of Domestic Partnership Application - Spanish (PDF, 65 KB) PDF None Spanish
DPH F-43020 Wisconsin Diabetes Strategic Plan Endorsement Word None English
DPH F-43020 Wisconsin Diabetes Strategic Plan Endorsement (PDF, 80 KB) PDF None English
DPH F-43026 Wisconsin Donor Registry Recovery Organization User Access Request Word None English
DPH F-43026 Wisconsin Donor Registry Recovery Organization User Access Request (PDF, 38 KB) PDF None English
DPH-00309A F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB) PDF None English
DPH-00309 F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB) PDF None English
HCF-10143 F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) PDF None English
HCF-10141 F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) PDF None English
HCF-01184 F-01184 Wisconsin Hemophilia Home Care Program Application (PDF, 49 KB) PDF None English
HCF-01184A F-01184A Wisconsin Hemophilia Home Care Program Application Instructions (PDF, 38 KB) PDF None English
HCF-01187 F-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement (PDF, 46 KB) PDF None English
HCF-01195 F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01187A F-01187A Wisconsin Hemophilia Home Care Program Financial Need Statement Instructions (PDF, 39 KB) PDF None English
HCF-01145 F-01145 Wisconsin Hemophilia Home Care Program Residency Verification (PDF, 20 KB) PDF None English
DPH-04257 F-44257 Wisconsin Immunization Record Card Paper Form Center English
DPH-05102 F-05102 Wisconsin Immunization Registry Exclusion Paper Program English
DDE-0483 F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request Word None English
DDE-0483 F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request (PDF, 16 KB) PDF None English
DDE-0441 F-20441 Wisconsin Incident Tracking System for Elder Abuse Reporting System None English
DPH-42017 F-42017 Wisconsin Initial Refugee Health Assessment Word None English
DPH-42017 F-42017 Wisconsin Initial Refugee Health Assessment (PDF, 366 KB) PDF None English
DPH F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB) PDF None English
HCF-11047 F-11047 Wisconsin Medicaid - Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 (PDF, 24 KB) PDF None English
HCF-11048 F-11048 Wisconsin Medicaid - Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission (PDF, 29 KB) PDF None English
HCF-01003 F-01003 Wisconsin Medicaid - Certification of Public Expenditures (PDF, 279 KB) PDF None English
HCF-11247 F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) Word None English
HCF-11247 F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) (PDF, 41 KB) PDF None English
HCF-11248 F-11248 Wisconsin Medicaid - Services that cannot be billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2) Word None English
HCF-11248 F-11248 Wisconsin Medicaid - Services that cannot be billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2) (PDF, 52 KB) PDF None English
HCF-12023 F-12023 Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption Paper Program English
HCF-12023S F-12023S Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption - Spanish Paper Program Spanish
HCF-12028 F-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request Paper Program English
HCF-12028A F-12028A Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request Completion Instructions Paper Program English
HCF-12089 F-12089 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request Paper Program English
HCF-12089A F-12089A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request Information and Instructions Paper Program English
HCF-12026 F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request Paper Program English
HCF-12026A F-12026A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request Completion Instructions Paper Program English
HCF-12027 F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request Paper Program English
HCF-12027A F-12027A Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request Completion Instructions Paper Program English
HCF-12025 F-12025 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request Paper Program English
HCF-12025A F-12025A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request Completion Instructions Paper Program English
HCF-12022 F-12022 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Provider Appeal Word None English
HCF-12022 F-12022 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Provider Appeal (PDF, 18 KB) PDF None English
HCF-11240 F-11240 Wisconsin Medicaid Case Management Provider Information Word None English
HCF-11240 F-11240 Wisconsin Medicaid Case Management Provider Information (PDF, 63 KB) PDF None English
HCF-01197 F-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation Word None English
HCF-01197 F-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation (PDF, 23 KB) PDF None English
HCF-01197A F-01197A Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation Completion Instructions (PDF, 15 KB) PDF None English
HCF-13066 F-13066 Wisconsin Medicaid Claim Refund Word None English
HCF-13066 F-13066 Wisconsin Medicaid Claim Refund (PDF, 69 KB) PDF None English
HCF-13066A F-13066A Wisconsin Medicaid Claim Refund Completion Instructions (PDF, 32 KB) PDF None English
HCF-11079 F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Excel None English
HCF-11079A F-11079A Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Completion Instructions (PDF, 36 KB) PDF None English
HCF-11080 F-11080 Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Excel None English
HCF-11080CP F-11080CP Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Excel None English
HCF-11080CA F-11080CA Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Completion Instructions (PDF, 35 KB) PDF None English
HCF-11080A F-11080A Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Completion Instructions (PDF, 35 KB) PDF None English
DMHSAS F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Community Recovery Services Provider Entities Word None English
DMHSAS F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-specified Community Recovery Services Providers Word None English
HCF-11260 F-11260 Wisconsin Medicaid Degree Addendum Word None English
HCF-11260 F-11260 Wisconsin Medicaid Degree Addendum (PDF, 24 KB) PDF None English
HCF-01009 F-01009A Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under Word None English
HCF-01009 F-01009A Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under (PDF, 23 KB) PDF None English
HCF-01009H F-01009AH Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Hmong Word None Hmong
HCF-01009H F-01009AH Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Hmong (PDF, 25 KB) PDF None Hmong
HCF-01009S F-01009AS Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Spanish Word None Spanish
HCF-01009S F-01009AS Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Spanish (PDF, 25 KB) PDF None Spanish
HCF-01009B F-01009B Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older Word None English
HCF-01009B F-01009B Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older (PDF, 22 KB) PDF None English
HCF-01009BH F-01009BH Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Hmong Word None Hmong
HCF-01009BH F-01009BH Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Hmong (PDF, 24 KB) PDF None Hmong
HCF-01009BS F-01009BS Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Spanish Word None Spanish
HCF-01009BS F-01009BS Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Spanish (PDF, 25 KB) PDF None Spanish
HCF-11245 F-11245 Wisconsin Medicaid Family Planning Clinics or Agencies Word None English
HCF-11245 F-11245 Wisconsin Medicaid Family Planning Clinics or Agencies (PDF, 52 KB) PDF None English
HCF-11129A F-11129A Wisconsin Medicaid Federally Qualified Health Center Cost Report Completion Instructions (PDF, 102 KB) PDF None English
HCF-11129B-H F-11129B-H Wisconsin Medicaid Federally Qualified Health Center Cost Report Forms Excel None English
HCF-11130 F-11130 Wisconsin Medicaid Federally Qualified Health Center Interim Report Excel None English
HCF-11130A F-11130A Wisconsin Medicaid Federally Qualified Health Center Interim Report Completion Instructions (PDF, 47 KB) PDF None English
HCF-10101S F-10101S Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) PDF None Spanish
HCF-10101 F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) Paper Form Center English
HCF-10101H F-10101H Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) PDF None Hmong
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan Word None English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan (PDF, 29 KB) PDF None English
HCF-11285 F-11285 Wisconsin Medicaid HealthCheck Screener Affirmation Word None English
HCF-11285 F-11285 Wisconsin Medicaid HealthCheck Screener Affirmation (PDF, 32 KB) PDF None English
HCF-13148 F-13148 Wisconsin Medicaid HIPAA Privacy Access Request (PDF, 178 KB) PDF None English
HCF-13149 F-13149 Wisconsin Medicaid HIPAA Privacy Accounting Request (PDF, 152 KB) PDF None English
HCF-13150 F-13150 Wisconsin Medicaid HIPAA Privacy Alternate Communication Request (PDF, 168 KB) PDF None English
HCF-13151 F-13151 Wisconsin Medicaid HIPAA Privacy Amendment Request (PDF, 151 KB) PDF None English
HCF-13145 F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure (PDF, 171 KB) PDF None English
HCF-13152 F-13152 Wisconsin Medicaid HIPAA Privacy Complaint (PDF, 158 KB) PDF None English
HCF-13147 F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request (PDF, 158 KB) PDF None English
HCF-13146 F-13146 Wisconsin Medicaid HIPAA Privacy Revocation of Authorization (PDF, 172 KB) PDF None English
HCF-01010 F-01010 Wisconsin Medicaid Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge Word None English
HCF-01010 F-01010 Wisconsin Medicaid Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge (PDF, 87 KB) PDF None English
HCF-01008 F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election Word None English
HCF-01008 F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election (PDF, 91 KB) PDF None English
HCF-01198 F-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services Word None English
HCF-01198 F-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services (PDF, 122 KB) PDF None English
HCF-01199 F-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration Word None English
HCF-01199 F-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration (PDF, 113 KB) PDF None English
HCF-11271 F-11271 Wisconsin Medicaid Personal Care Provider Addendum Word None English
HCF-11271 F-11271 Wisconsin Medicaid Personal Care Provider Addendum (PDF, 22 KB) PDF None English
HCF-01011 F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness Word None English
HCF-01011 F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness (PDF, 92 KB) PDF None English
HCF-11278 F-11278 Wisconsin Medicaid PreNatal Care Coordination Outreach and Management Plan Word None English
HCF-11278 F-11278 Wisconsin Medicaid PreNatal Care Coordination Outreach and Management Plan (PDF, 55 KB) PDF None English
HCF-11252 F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum Word None English
HCF-11252 F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum(PDF, 46 KB) PDF None English
HCF-01812 F-01812 Wisconsin Medicaid Program Nursing Home Cost Report (PDF, 512 KB) PDF None English
HCF-01812A F-01812A Wisconsin Medicaid Program Nursing Home Cost Report Instructions (PDF, 544 KB) PDF None English
HCF-01018 F-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers Word None English
HCF-01018 F-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers (PDF, 235 KB) PDF None English
HCF-01134 F-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit Word None English
HCF-01134 F-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit (PDF, 77 KB) PDF None English
HCF-01149 F-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements Word None English
HCF-01149 F-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements (PDF, 45 KB) PDF None English
HCF-11025A F-11025A Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary (PDF, 20 KB) Encounters Submitted to Medicaid HMOs Instructions (PDF, 20 KB) PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary (PDF, 37 KB) Encounters Submitted to Medicaid HMOs (PDF, 37 KB) PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs Word None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Word None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs (PDF, 30 KB) PDF None English
HCF-11026A F-11026A Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Completion Instructions (PDF, 25 KB) PDF None English
HCF-11081 F-11081 Wisconsin Medicaid Rural Health Clinic Provider Staff Encounters Excel None English
HCF-11027 F-11027 Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Excel None English
HCF-11027A F-11027A Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Instructions (PDF, 32 KB) PDF None English
HCF-11023 F-11023 Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Excel None English
HCF-11023A F-11023A Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Completion Instructions (PDF, 27 KB) PDF None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data Word None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data (PDF, 54 KB) PDF None English
HCF-11296 F-11296 Wisconsin Medicaid SMV Transportation Service Informational (PDF, 61 KB) PDF None English
HCF-11237 F-11237 Wisconsin Medicaid Specialized Medical Vehicle Provider Affidavit Word None English
HCF-11237 F-11237 Wisconsin Medicaid Specialized Medical Vehicle Provider Affidavit (PDF, 69 KB) PDF None English
HCF-01050 F-01050 Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification (PDF, 67 KB) PDF None English
HCF-01050A F-01050A Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions (PDF, 332 KB) PDF None English
HCF-12024 F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model Paper Program English
HCF-12024A F-12024A Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model Completion Instructions Paper Program English
HCF-10140 F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) PDF None English
HCF-10140S F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) PDF None Spanish
HCF-01017 F-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Word None English
HCF-01017 F-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement (PDF, 37 KB) PDF None English
HCF-01017A F-01017A Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Completion Instructions (PDF, 35 KB) PDF None English
HCF-01302 F-01302 Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report Word None English
HCF-01302 F-01302 Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report (PDF, 113 KB) PDF None English
HCF-01302A F-01302A Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report Instructions (PDF, 25 KB) PDF None English
DPH-45038 F-45038 Wisconsin Mercury Exposure Study Paper Program English
DQA F-00812 Wisconsin Music and Memory Initiative Nursing Home Application Word None English
DPH-40097 F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement (PDF, 82 KB) PDF None English
DPH-43023 F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC) (PDF, 291 KB) PDF None English
DPH-43024 F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) (PDF, 200 KB) PDF None English
DDE-1283 F-21283 Wisconsin Public Psychiatry Network Teleconference Evaluation System None English
DDE-2642 F-22642 Wisconsin Public Psychiatry Network Teleconference Evaluation (PDF, 52 KB) PDF None English
HCF-13162 F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request (PDF, 183 KB) PDF None English
HCF-13163 F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request (PDF, 152 KB) PDF None English
HCF-13164 F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request (PDF, 163 KB) PDF None English
HCF-13165 F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request (PDF, 154 KB) PDF None English
HCF-13161 F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure (PDF, 178 KB) PDF None English
HCF-13166 F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint (PDF, 157 KB) PDF None English
HCF-13168 F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request (PDF, 155 KB) PDF None English
HCF-13167 F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization (PDF, 171 KB) PDF None English
DPH F-00124S Wisconsin Termination Domestic Partnership Certificate Application - Spanish (PDF, 77 KB) PDF None Spanish
DPH F-00124 Wisconsin Termination Domestic Partnership Certificate Application (PDF, 50 KB) PDF None English
DMHSAS F-00037H Wisconsin Trauma-Informed Care (TIC) Listserve HTML None 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
DMHSAS F-00115 Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument Word None English
DMHSAS F-00115S Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument - Spanish Word None Spanish
HCF-10147 F-10147 Wisconsin Veterans Home at King - Medicaid Review (PDF, 253 KB) PDF None English
HCF-10075 F-10075 Wisconsin Well Woman Medicaid Determination (PDF, 78 KB) Paper Form Center English
DPH-04818 F-44818 Wisconsin Well Woman Program (How to order form) (PDF, 390 KB) PDF None English
DPH-43021 F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral Paper Program English
HCF-13509 F-13509 Wisconsin Well Woman Program Provider Certification (PDF, 388 KB) PDF None English
DPH-04089 F-44089 Wisconsin WIC Checks Accepted Here - Stickers Paper Form Center English
DPH-40034 F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing Word None English
DPH-40036 F-40036 Wisconsin Women, Infant, and Children (WIC) Program Vendor Agreement (PDF, 45 KB) PDF None English
DLTC F-00272 WisTech Assistive Technology Advisory Council Member Application Word None English
DLTC F-00252 Work Incentive Benefits Counseling Project - Prior Authorization Word None English
HFS-0018C F-82018C Work Time Absence Record - 2014 Excel - Fillable Form Center English
HFS-0018C F-82018C Work Time Absence Record - 2014 (PDF, 791 KB) PDF Form Center English
DPH-40098 F-40098 Worksite Wellness Kit Survey and Request Word None English
DPH-40098 F-40098 Worksite Wellness Kit Survey and Request (PDF, 147 KB) PDF None English
DPH-42019 F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results (PDF, 95 KB) PDF None English
DLTC F-00315D Written Prior Notice - Additional Assessments Recommended Word None English
DLTC F-00315D Written Prior Notice - Additional Assessments Recommended (PDF, 14 KB) PDF None English
DLTC F-00315DS Written Prior Notice - Additional Assessments Recommended - Spanish (PDF, 15 KB) PDF None Spanish
DLTC F-00315 Written Prior Notice - Birth to 3 Word Form Center English
DLTC F-00315 Written Prior Notice - Birth to 3 (PDF, 14 KB) PDF Form Center English
DLTC F-00315S Written Prior Notice - Birth to 3 - Spanish (PDF, 16 KB) PDF None Spanish
DLTC F-00315A Written Prior Notice - No Evaluation - Birth to 3 Word None English
DLTC F-00315A Written Prior Notice - No Evaluation - Birth to 3 (PDF, 12 KB) PDF None English
DLTC F-00315AS Written Prior Notice - No Evaluation - Birth to 3 - Spanish (PDF, 16 KB) PDF None Spanish
DPH F-00375 Yellow Fever Uniform Stamp Application (PDF, 32 KB) PDF None English
DHCAA F-10150B Your Rights and Responsibilities for FoodShare (PDF, 81 KB) PDF None English
DHCAA F-10150BS Your Rights and Responsibilities for FoodShare - Spanish (PDF, 60 KB) PDF None English
DHCAA F-10150A Your Rights and Responsibilities for Health Care (PDF, 56 KB) PDF None English
DHCAA F-10150AS Your Rights and Responsibilities for Health Care - Spanish (PDF, 56 KB) PDF None English
HCF-10150S F-10150S Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) PDF None Spanish
HCF-10150 F-10150 Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) PDF None English
DLTC F-00676A Youth Transition Post-Test Word None English
DLTC F-00676 Youth Transition Pre-Test Word None English

Last Revised:  May 22, 2013