Forms Library

Forms produced by the Wisconsin Department of Health Services (DHS) are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy.

Searching Tips

  • If you know the number of the form, enter just the number in the "Search Forms" box below. Example, if you are looking for F-00004, just enter "4" or "00004."
  • If you only know the title of the form, enter it in the green "Search Wisconsin DHS" box at the top of the page and click the magnifying glass.

Microsoft Word 2010

Many of our forms are fillable Word 2003 or Word 2010 files; Microsoft Word Viewer software is available as a free download.

  • If you do not have Microsoft Word, use Microsoft Word viewer to view Word files. This product, available free of charge, is a viewer only and does not allow you to make changes to Word documents.
  • If you have MS Word 2003 or an earlier version, use the Microsoft Word 2007 compatibility pack to access a Word 2010 file.

NOTE: When downloading a Word form, you may get a Windows Security popup box asking for a login ID and a password. The form will open if you choose "Cancel."

Assigned Numbersort descending Title Division Other Location Language
F-00004 Health and Employment Counseling Application DLTC English
F-00004A Health and Employment Counseling - I Think I Need More Time (PDF, 35 KB) DLTC English
F-00004B Health and Employment Counseling - I Have Reached Employment (PDF, 23 KB) DLTC English
F-00005 Senior FMNP Agency Application to Participate DPH English
F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) DHCAA English
F-00010 Risk Agreement - Participant DLTC English
F-00012 CBRF Completion Documents (PDF, 18 KB) DQA English
F-00014 Ceiling Closure Inspection Checklist DQA English
F-00015 Final Occupancy Inspection Checklist DQA English
F-00016 Wall Closure Inspection Checklist DQA English
F-00017 Blood Lead Lab Reporting DPH English
F-00018 Swimming Pool and Water Attraction Fecal Incident Report (PDF, 21 KB) DPH English
F-00020 Drug Addition Review Request DHCAA English
F-00021 HealthCheck Referral (PDF, 18 KB) DHCAA English
F-00022 Nursing Home Rate Administrative Review Request DLTC English
F-00023 Case Management Agency Self-Audit Checklist (PDF, 191 KB) DHCAA English
F-00024 HSRS Core Summary Report OS English
F-00027 CSAS Standards Recertification Application - DHS 75.03 DQA English
F-00030 State Maximum Allowed Cost Drug Pricing Review Request DHCAA English
F-00036 Power of Attorney for Finance and Property DPH English
F-00037 Functional Screen Listserv Sign-Up DLTC, DMHSAS English
F-00037C DLTC and DMHSAS Memo Series E-Mail Subscription Services Sign-Up DLTC, DMHSAS English
F-00037D DQA E-Mail Subscription Service Sign-Up DQA English
F-00037G ADRC Quality Improvement Listserv DLTC English
F-00037H Wisconsin Trauma-Informed Care (TIC) Listserve DMHSAS English
F-00039 Asbestos Course Accreditation - Initial (PDF, 83 KB) DPH English
F-00040 Asbestos Course Accreditation - Renewal (PDF, 27 KB) DPH English
F-00041 Asbestos Project Notification DPH English
F-00042 Knowledge Journal DES English
F-00043 Communication to Local Educational Agency Regarding Child Referral DLTC English
F-00044 User Agreement for System Access DES English
F-00046 Family Care Program - Enrollment DLTC English
F-00047 Designated Asbestos Coordinator (PDF, 39 KB) DPH English
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) DPH English
F-00049 Asbestos Principal Instructor (PDF, 30 KB) DPH English
F-00050 Oral Health Preliminary Exam and Prevention Services (PDF, 43 KB) DLTC English
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) DPH English
F-00052 Aging and Disability Resource Center (ADRC) Application DLTC English
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget DLTC English
F-00052B CARES Data Access and Use Agreement (ADRC) DLTC English
F-00053 Notice of Intent to Submit an Application (ADRC) DLTC English
F-00054 Request for Waiver of Education / Experience Requirements (ADRC) DLTC English
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DLTC English
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DLTC English
F-00054D Request for Waiver of the .5 Full-Time Equivalent Requirement for ADRC Staff DLTC English
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA English
F-00060 Declaration to Physicians (Living Will) DPH English
F-00067 PROAct - Program Review Outcome / Activity Person-Centered Field Review Report DLTC English
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DLTC English
F-00076 Variance Request - Wait List DLTC English


Last Revised: February 16, 2016