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-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS
F-02666 Prior Authorization Drug Attachment for Headache Agents, Acute Treatment DMS
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS
F-02667 Prior Authorization Drug Attachment for Headache Agents, Preventative Treatment DMS
F-05021 Report of Legal Name Change DPH
F-05021C Report of Legal Name Change - Confidential DPH
F-03068 State Dementia Plan Event Tracker OPIB
F-05021T Report of Legal Name Change - Tribal DPH
F-03031 Wisconsin Asthma-Safe Homes Program Education Services Provider Grant Application DPH
F-03032 Wisconsin Asthma-Safe Homes Program Environmental Services Provider Grant Application DPH
F-10097A Community-Based Long-Term Care Services Medicaid Income Allocation DMS
F-10097 Institutional Medicaid Income Allocation DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-44243 Sexually Transmitted Infections Laboratory and Morbidity Case Report DPH
F-03054 2022-2023 K-12 COVID-19 Testing Program Participation DPH
F-02007 WI HPP Exercise and Real Event Report DPH
F-03053 Naloxone Virtual Train-the-Trainer Course Registration DCTS
F-03023 Title X Expenditure Report by Profile DPH
F-00943 Exhibit II: Tribal Work Plan OS
F-02903 DHS Office of the Secretary External Event Request OS
F-40106 Breast Pump Loan and Release Agreement DPH
F-03051 Tick Identification DPH
F-03050 MC4JR Partnership Snapshot DPH
F-00054 ADRC/Aging/Tribal Agency Request for Approval of Alternative Staff Experience and/or Training DPH
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report DQA
F-00107 Self-Employment Income Report DMS
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS
F-01207A IRIS Fiscal / Employer Agent Quality Management Plan Tracking DMS
F-83271 DHS Website Feedback OS
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis DMS
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events DPH
F-01208A IRIS Consultant Agency Quality Management Plan Tracking DMS
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) DPH
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-01389B MHSIP Family Satisfaction Survey DCTS
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-01415 IRIS Adult Family Home Taxable Income Information DMS
F-00989-Packet Individualized Family Service Plan (IFSP) Packet DMS
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report DPH
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS
F-00642 Community Aids Reporting System (CARS) Expenditure Report DES
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS

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Last Revised: June 16, 2022