Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Location
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-02863 Disability Benefit Specialist Program Appointed Representative Agreement DPH
F-02879 Vulnerable/High Risk Determination – IRIS Program DMS
F-01389 MHSIP Adult Satisfaction Survey DCTS
F-01423 AIDS/HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-01389B MHSIP Family Satisfaction Survey DCTS
F-02866 FoodShare Request for Proof DMS
F-44727 WIC Vendor Proof of Training DPH
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting DMS
F-02874 Letter: Screen Visit Scheduled DMS
F-02876 Letter: Screen Visit Not Scheduled DMS
F-01118 Child Care Coordination Family Questionnaire DMS
F-02875 Self-Care Assessment DPH
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-05042 Fetal Death Worksheet DPH
F-16066 FoodShare Wisconsin Income Change Report DMS
F-02870 Demographic Assessment for Communities, Boards, Workgroups, and Councils DPH
F-02871 emPOWER Data Use Evaluation DPH
F-00047 Designated Asbestos Coordinator DPH
F-02872 Trauma Care Facility Site Reviewer Performance Assessment DPH
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-44002 Asbestos Certification Application - Company DPH
F-44017 Asbestos Application - Individual DPH
F-16033 FoodShare Worksheet DMS
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-00201 Occupant Protection Plan Checklist for Lead Abatement Activities DPH
F02761 Health Care Entity Staffing Request CRT
F-62069 Home Health Agency Complaint Report DQA
F-05022F Report of Adoption for a Child Born In A Foreign Country DPH
F-05093 Court Order to Amend a Wisconsin Marriage Certificate DPH
F-05091 Report of Court Order to Amend a Wisconsin Birth Certificate DPH
F-02857 YCSF Request for Exception-Age DCTS
F-05021 Report of Legal Name Change DPH
F-05092 Court Order to Amend a Wisconsin Death Certificate DPH
F-05098 Report of Court Order to Correct Facts Misrepresented by Informant for a Wisconsin Birth Record DPH
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES) DMS
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-05022 Report of Adoption DPH
F-05032 Report of Order for Birth Record Changes Following Surrogate Birth DPH
F-02860 Information and Assistance Supervisor Observation and Support Tool DPH
F-02069 DHS Quarterly Report on Consumers Enrolled in CCS DCTS
F-02861 Options Counseling Supervisor Observation and Support Tool DPH
F-04002 School Report to Local Health Department DPH
F-02859 DPH Speaker Request DPH
F-44243A Congenital Syphilis Case Investigation Report DPH
F-10193 Divestment Penalty and Undue Hardship Notice Plus Waiver Request DMS
F-01204A Letter – IRIS Program Notice of Action – Denial DMS
F-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-01204C Letter – IRIS Program Notice of Action – Reduction DMS


Last Revised: March 23, 2021