Skip to main content

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 Division Language Release date File type Available to order
F-25213 Admission to Caseload - Mental Health DCTS English 12/2016 PDF No
F-25213 Admission to Caseload - Mental Health DCTS English 12/2016 Word No
F-25904 Admission to Caseload - Revocation DCTS English 01/2017 PDF No
F-25904 Admission to Caseload - Revocation DCTS English 01/2017 Word No
F-03377 Adolescent Inpatient Mental Health Program DHS 61.79 - Applicant Compliance Statement DQA English 05/2025 Word No
F-02057 ADRC Authorization for the Release of Confidential Information DPH English 08/2017 Word No
F-02057S ADRC Authorization for the Release of Confidential Information, Spanish DPH Spanish 08/2017 Word No
F-02715 ADRC Client Tracking System Waiver Request DPH English 09/2020 Word No
F-02882 ADRC Dementia Care Specialist Work Plan Template DPH English 09/2021 Word No
F-02881 ADRC Dementia-Capable Training Plan DPH English 09/2021 Word No
F-00052D ADRC Dissolution Planning Checklist DPH English 01/2023 Word No
F-02880 ADRC Location and Physical Space Self-Assessment DPH English 09/2021 Word No
F-02714 ADRC Professional Training Participant Survey DPH English 09/2020 HTML No
F-02053 ADRC Referral to Income Maintenance for Managed Long-Term Care Services DPH English 03/2021 Word No
F-03093 ADRC Specialist Customer Service Agreement DPH English 09/2022 PDF No
F-03093DS ADRC Specialist Customer Service Agreement (DocuSign) DPH English 09/2022 HTML No
F-03093H ADRC Specialist Customer Service Agreement, Hmong DPH Hmong 09/2022 PDF No
F-03093S ADRC Specialist Customer Service Agreement, Spanish DPH Spanish 09/2022 PDF No
F-00054 ADRC/Aging/Tribal Agency Request for Approval of Alternative Staff Experience and/or Training DPH English 06/2022 Word No
F-02000 ADRC/Aging/Tribal User System Access Request DPH English 04/2025 HTML No
F-02000A ADRC/Aging/Tribal User System Access Request: Form Instructions DPH English 04/2025 PDF No
F-03267 Adult Day Care Center (ADCC) Certification Application DQA English 01/2024 Word No
F-02634 Adult Day Care Center (ADCC) Initial Survey Checklist DQA English 02/2023 Word No
F-02106 Adult Day Care Center - Applicant Compliance Statement DQA English 01/2022 Word No
F-03129 Adult Day Care Center Caregiver/Staff Record Review DQA English 01/2025 Word No
F-03122 Adult Day Care Center Environmental Review DQA English 07/2023 Word No
F-03128 Adult Day Care Center Participant Records Review DQA English 02/2023 Word No
F-03145 Adult Day Care Center Self-Report DQA English 04/2023 Word No
F-02106A Adult Day Care Center: Certification Application DQA English 11/2022 Word No
F-02106B Adult Day Care Center: Certification Application Checklist DQA English 12/2021 Word No
F-03124 Adult Day Care Center: Home and Community Based Service (HCBS) Review - Benchmark Review and Compliance Report DQA English 02/2024 Word No
F-02634A Adult Family Home (AFH) Initial Survey Checklist DQA English 03/2020 Word No
F-02108 Adult Family Home - Applicant Compliance Statement DQA English 01/2024 Word No
F-02108B Adult Family Home - Established Provider Licensure Application Checklist DQA English 08/2022 Word No
F-02108D Adult Family Home - New Provider Licensure Application Checklist DQA English 08/2022 Word No
F-60953 Adult Family Home Fire Safety Guide DQA English 12/2015 PDF No
F-60953 Adult Family Home Fire Safety Guide DQA English 12/2015 Word No
F-03375 Adult Inpatient Mental Health Program DHS 61.71 - Applicant Compliance Statement DQA English 05/2025 Word No
F-03290 Adult Inpatient Program Initial Certification Application - DHS 61.71 DQA English 06/2024 Word No
F-03250 Adult Long-Term Care (LTC) Waiver Provider Application Information and Instructions DMS English 02/2025 PDF No
F-03250 Adult Long-Term Care (LTC) Waiver Provider Application Information and Instructions DMS English 02/2025 Word No
F-01315 AFDC-Related Determination Worksheet DMS English 07/2014 PDF No
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH English 09/2019 Word No
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH English 08/2023 PDF No
F-40019H Affirmation of Identity, Residency, Income, or Benefit Loss, Hmong DPH Hmong 08/2023 PDF No
F-40019S Affirmation of Identity, Residency, Income, or Benefit Loss, Spanish DPH Spanish 08/2023 PDF No
F-02220 AFH Exceptions DMS English 08/2024 HTML No
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years DMS English 02/2017 PDF No
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months DMS English 02/2017 PDF No
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years DMS English 02/2017 PDF No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised December 4, 2024