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-02108C Adult Family Home – New Provider Licensure Application DQA
F-02107C Family Adult Day Care Center – New Provider Certification Application DQA
F-02109A CBRF – Established Provider Licensure Application DQA
F-02107 Family Adult Day Care Center – Applicant Compliance Statement DQA
F-02107D Family Adult Day Care Center – New Provider Certification Application Checklist DQA
F-12024 Wisconsin Medicaid HMO Enrollment Choice DMS
F-12025 Wisconsin BadgerCare Plus HMO Enrollment Choice DMS
F-01338 Children's Long-Term Support Parental Fee Declaration – Model DMS
F-01814 County Agency Children’s Community Options Program (CCOP) Five-Year Plan DMS
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-62333 Plan Approval Application and Instructions DQA
F-01320 Lead Test Kit Documentation DPH
F-02788 Certified Narcotic Treatment Service for Opiate Addiction: Medication Unit Application DQA
F-02610B Occupant Worksheet - Lead-Safe Homes Program Application DPH
F-02782 Coalition to End Social Isolation and Loneliness – Stakeholder Engagement Survey DPH
F-02784 PASRR 30-Day Information Required for PASRR Exemption Letter Request DCTS
F-02610A Rental Property - Lead-Safe Homes Program Application DPH
F-01201A IRIS Participant-Hired Worker Relationship Identification DMS
F-11317 Certification Criteria for Providers Express Enrollment of Pregnant Women in BadgerCare Plus OIG
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-02573 Prior Authorization Drug Attachment for Wakix DMS
F-00978 Confirmation of Confidential Data Destruction - Wisconsin Cancer Reporting System (WCRS) DPH
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-01885 Requesting State Trauma Registry Access DPH
F-62062 Hospice License Application DQA
F-10098 Medicaid Member Asset Allocation DMS
F-00533 Partnership Programs — Enrollment DPH
F-00046 Family Care Program — Enrollment DPH
F-02720A Family Caregiver Support Program Post Evaluation DPH
F-02483 PACE Program Enrollment DPH
F-02720 Family Caregiver Support Program Initial Evaluation DPH
F-02053 ADRC Referral to Income Maintenance for Managed Long-Term Care Services DPH
F-25180 Order of Discharge Upon Expiration of Commitment DCTS
F-25206 Petition for Capias DCTS
F-25207 Order Granting Capias DCTS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS
F-25177 Statement of Probable Cause and Detention and Petition for Revocation DCTS
F-02733 Request for Community Spouse Signature DMS
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-00075 IRIS (Include, Respect, I Self-Direct) Authorization 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-02140 Urgent Services Agreement DPH
F-02702 Pre-Release Enrollment Agreement DPH

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Last Revised: June 16, 2022