Official DHS Forms Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions. When you are searching for a document, enter the number or a portion of the title in the search box below. To narrow your search results even more, place quotation marks (" ") around search terms.

If you are looking for an informative document, visit our Informative Documents and Publications Library. If you need a file in another file format or can't find what you are looking for here, reach out to the Digital Communications Team at dhsfmorder@dhs.wisconsin.gov. You can typically expect a response within 1-2 business days.

Assigned number Title Sort descending Division Language Release date File type Available to order
F-02663 Letterhead - EVV Personal Identification Number (PIN) DMS English 02/2021 HTML
F-47484 Level III Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word
F-47484A Level IV Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word
F-62019 License Application for Nursing Home, Intermediate Care Facility - Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA English 04/2025 Word
F-01022 License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS English 02/2017 Excel
F-00165E Limited English Proficiency (LEP) Customer Data Analysis Chart OLC English 12/2021 Word
F-02731 Line List: Respiratory Virus Outbreak - Workplace Environment DPH English 10/2020 Excel
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF
F-03036 Local and Tribal Health Department (LTHD) Antigen Test Distribution Program Participation Attestation DPH English 05/2022 PDF
F-01573 Log of Ice Arena Air Quality DPH English 06/2015 Word
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 09/2024 PDF
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 09/2024 Word
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 09/2024 PDF
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 09/2024 Word
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 09/2024 Word
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 09/2024 PDF
F-03301 Long-Term Care (LTC) Waiver HCBS Settings Rule Community-Based Provider Attestation DMS English 02/2025 Word
F-03301 Long-Term Care (LTC) Waiver HCBS Settings Rule Community-Based Provider Attestation DMS English 02/2025 PDF
F-03245 Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 09/2024 Word
F-03245 Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 09/2024 PDF
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 09/2024 Word
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 09/2024 PDF
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 09/2024 Word
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 09/2024 PDF
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation DMS English 09/2024 PDF
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation DMS English 09/2024 Word
F-03302 Long-Term Care (LTC) Waiver Remote Monitoring and Support Attestation DMS English 02/2025 Word
F-03302 Long-Term Care (LTC) Waiver Remote Monitoring and Support Attestation DMS English 02/2025 PDF
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation DMS English 09/2024 Word
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation DMS English 09/2024 PDF
F-03238 Long-Term Care (LTC) Waiver Supported Employment and Competitive Integrated Employment Attestation DMS English 02/2025 PDF
F-03238 Long-Term Care (LTC) Waiver Supported Employment and Competitive Integrated Employment Attestation DMS English 02/2025 Word
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation DMS English 09/2024 Word
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation DMS English 09/2024 PDF
F-03240 Long-Term Care (LTC) Waiver Transportation Attestation DMS English 09/2024 Word
F-03240 Long-Term Care (LTC) Waiver Transportation Attestation DMS English 09/2024 PDF
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation DMS English 09/2024 Word
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation DMS English 09/2024 PDF
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation DMS English 09/2024 Word
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation DMS English 09/2024 PDF
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA English 06/2024 Word
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 Word
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 PDF
F-01567S Long-Term Care Insurance Policy - Assignment of Benefits, Spanish DMS Spanish 12/2018 PDF
F-03069 LTHD COVID-19 Antigen Test Distribution Program DPH English 04/2023 HTML
F-02188 Lyme Disease Case Worksheet DPH English 02/2022 PDF
F-02946 Management Evaluation Review (MER) Advocate Survey DMS English 01/2025 HTML
F-02945 Management Evaluation Review (MER) Income Maintenance (IM) Staff Survey DMS English 01/2025 HTML

Glossary

 
Last revised December 4, 2024