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.

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 Instructions and Important Information 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: November 2, 2015