Forms Library

Forms produced by the Wisconsin Department of Health Services 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. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Number Title Other Location
F-44019A Immunization Assessment
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators
F-44018 Request for Repairs
F-44257 Wisconsin Immunization Record Card
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units)
F-44011 Application for Registration of Lead-Free or Lead-Safe Property
F-44126 Antituberculosis Therapy Program Medication Refill Request
F-45008 Application for Radioactive Material License for Medical Use
F-44215 Child Care Center Report to the District Attorney
F-00480 Child Outcomes Summary
F-42016 Authorization for Release of Confidential HIV Test Results
F-43016 Prevent Heart Disease & Stroke Wallet Card
F-42017 Wisconsin Initial Refugee Health Assessment
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral
F-42014 Acuity Index
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC)
F-42023 Vaccine Celsius Temperature Log
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC)
F-42024 Vaccine Fahrenheit Temperature Log
F-42010 Interjurisdictional Tuberculosis Notification
F-43009 Diabetes Emergency Action Plan
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program
F-43026 Wisconsin Donor Registry User Access Request
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up
F-43013 Diabetes Medical Management Plan
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-42000 Vaccine Order
F-42001 Tuberculosis Suspect Case Data
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services
F-02124 2016 Comprehensive Community Services (CCS) Program Survey Worksheet
F-01234 Explanation of Medical Benefits
F-02074 Medicare Other Coverage Discrepancy Report
F-02112 2017 Community Support Program (CSP) Survey Worksheet
F-62320 Hospice Survey Information
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys
F-25177 Statement of Probable Cause and Detention and Petition for Revocation
F-10076 SeniorCare Application
F-40303 Early Childhood Caries Prevention Screening
F-62319 Hospice Volunteer Program Review
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-40092 Physical Activity Zone
F-40072 8 Week Activity Log
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS
F-40019 Affirmation of Identity, Residency, and/or Income
F-40117 Abortion Information Provision Certification
F-40073 Monthly Physical Activity Sheet
F-40028 Participant Determination Letter
F-40062 TEFAP / CSFP Commodity Loss Report

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Last Revised: May 22, 2018