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.
- About PDF Forms
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- If you only know the title of the form, enter it in the green "Search Wisconsin DHS" box at the top of the page.
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|Assigned Number||Title||Division||Other Location||Language|
|F-00004||Health and Employment Counseling Application||DLTC||None||English|
|F-00004A||Health and Employment Counseling - I Think I Need More Time (PDF, 35 KB)||DLTC||None||English|
|F-00004B||Health and Employment Counseling - I Have Reached Employment (PDF, 23 KB)||DLTC||None||English|
|F-00005||Senior FMNP Agency Application to Participate||DPH||None||English|
|F-00009||Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB)||DHCAA||None||English|
|F-00010||Risk Agreement - Participant||DLTC||None||English|
|F-00012||CBRF Completion Documents (PDF, 18 KB)||DQA||None||English|
|F-00014||Ceiling Closure Inspection Checklist||DQA||None||English|
|F-00015||Final Occupancy Inspection Checklist||DQA||None||English|
|F-00016||Wall Closure Inspection Checklist||DQA||None||English|
|F-00017||Blood Lead Lab Reporting||DPH||None||English|
|F-00018||Swimming Pool and Water Attraction Fecal Incident Report (PDF, 21 KB)||DPH||None||English|
|F-00020||Drug Addition Review Request||DHCAA||None||English|
|F-00021||HealthCheck Referral (PDF, 18 KB)||DHCAA||None||English|
|F-00022||Nursing Home Rate Administrative Review Request||DLTC||None||English|
|F-00023||Case Management Agency Self-Audit Checklist (PDF, 191 KB)||DHCAA||None||English|
|F-00024||HSRS Core Summary Report||OS||None||English|
|F-00027||CSAS Standards Recertification Application - DHS 75.03||DQA||None||English|
|F-00030||State Maximum Allowed Cost Drug Pricing Review Request||DHCAA||None||English|
|F-00036||Power of Attorney for Finance and Property||DPH||None||English|
|F-00037||Functional Screen Listserv Sign-Up||DLTC, DMHSAS||None||English|
|F-00037C||DLTC and DMHSAS Memo Series E-Mail Subscription Services Sign-Up||DLTC, DMHSAS||None||English|
|F-00037D||DQA E-Mail Subscription Service Sign-Up||DQA||None||English|
|F-00037G||ADRC Quality Improvement Listserv||DLTC||None||English|
|F-00037H||Wisconsin Trauma-Informed Care (TIC) Listserve||DMHSAS||None||English|
|F-00039||Asbestos Course Accreditation - Initial (PDF, 83 KB)||DPH||None||English|
|F-00040||Asbestos Course Accreditation - Renewal (PDF, 27 KB)||DPH||None||English|
|F-00041||Asbestos Project Notification||DPH||None||English|
|F-00043||Communication to Local Educational Agency Regarding Child Referral||DLTC||None||English|
|F-00044||User Agreement for System Access||DES||None||English|
|F-00046||Family Care Program Enrollment Instructions and Important Information||DLTC||None||English|
|F-00047||Designated Asbestos Coordinator (PDF, 39 KB)||DPH||None||English|
|F-00048||Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s)||DPH||None||English|
|F-00049||Asbestos Principal Instructor (PDF, 30 KB)||DPH||None||English|
|F-00050||Oral Health Preliminary Exam and Prevention Services (PDF, 43 KB)||DLTC||None||English|
|F-00051||Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s)||DPH||None||English|
|F-00052||Aging and Disability Resource Center (ADRC) Application||DLTC||None||English|
|F-00052A||Aging and Disability Resource Center (ADRC) Annual Budget||DLTC||None||English|
|F-00052B||CARES Data Access and Use Agreement (ADRC)||DLTC||None||English|
|F-00053||Notice of Intent to Submit an Application (ADRC)||DLTC||None||English|
|F-00054||Request for Waiver of Education / Experience Requirements (ADRC)||DLTC||None||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||None||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||None||English|
|F-00054D||Request for Waiver of the .5 Full-Time Equivalent Requirement for ADRC Staff||DLTC||None||English|
|F-00059||Outpatient Mental Health Clinic Application - DHS 35||DQA||None||English|
|F-00060||Declaration to Physicians (Living Will)||DPH||Other||English|
|F-00067||PROAct - Program Review Outcome / Activity Person-Centered Field Review Report||DLTC||None||English|
|F-00075||IRIS (Include, Respect, I Self-Direct) Authorization||DLTC||None||English|
|F-00076||Variance Request - Wait List||DLTC||None||English|