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-02733 Request for Community Spouse Signature DMS
F-25206 Petition for Capias DCTS
F-25207 Order Granting Capias DCTS
F-10097A Community-Based Long-Term Care Services Medicaid Income Allocation DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions DPH
F-21334 Encounter New User Request DMS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-44126 Antituberculosis Therapy Program Medication Refill Request DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-02764 Participant Fiscal Employer Agent (FEA) – Transfer Request DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-16019A FoodShare Wisconsin Registration DMS
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS
F-02022 Claims Audit Report for Managed Long-Term Care MCOs DMS
F-02702 Pre-Release Enrollment Agreement DPH
F-02140 Urgent Services Agreement DPH
F-82064 Background Information Disclosure (BID) DQA
F-02768 COVID-19 Wasted Vaccine Record DPH
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs DPH
F-02047 IRIS Financial Reporting Template DMS
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting DMS
F-02605 Home and Community-Based Services (HCBS) Settings Rule DMS
F-10112 Medicaid Disability Application DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application DMS
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement DPH
F-04020L Student Immunization Record, Long DPH
F-00963 Children’s Long Term Support Reconciliation Packet DMS
F-02763 Acute Hospital Care at Home Program: Emergency Request for Approval DQA
F-02663 Letterhead – EVV Personal Identification Number (PIN) DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-00780 Options Counseling Tip Card DPH
F-02771 COVID-19 Ventilation Checklist CRT
F-01997 Children's Community Options (CCOP) Reconciliation Packet DMS
F-01628 OARS Enrollment Letter DCTS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-01942C LTC FS - Release of Information Authorization DMS
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline DMS
F-02602 1-2 Bed Adult Family Home Certification Application Request DMS
F-01942D LTC FS - Change in Condition - Release of Information Authorization DMS
F-01442C IRIS Program Disenrollment Letter – No Contact DMS
F-01619 OARS Welcome Letter DCTS

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Last Revised: March 23, 2021