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-01769 TEFAP Soup Kitchen Self-Assessment
F-01767 TEFAP Shelter Self-Assessment Tool
F-01748 Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-01710 Home Health Agency Initial Licensure Checklist
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire
F-01930 Minority Health Advisory Group Nomination and Agreement
F-62579 Post Survey Questionnaire
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO
F-01621 Smoking Cessation Data Collection
F-01622 OARS Records Checklist
F-01627 OARS Provider Case Manager Checklist
F-01623 OARS - Residential Placement Reviews
F-01625 OARS Participant Discharge Summary
F-20572 Request for State Public Funding for Non-Residents
F-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request
F-82069 Background Information Disclosure (BID) Appendix
F-01682 Wisconsin State Certified Peer Specialist Trainer Application
F-01336 Wisconsin Assessment of the Impaired Driver (WAID) and Other Substance Users
F-01681 Comprehensive Community Services (CCS) Technical Assistance Survey
F-20389 DCTS Program Performance Report
F-01761 Intoxicated Driver Program Self-Evaluation
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s)
F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook
F-01341 Pre-Release from Institution Checklist (CM Checklist)
F-01601B ISP Line Item Detail Budget
F-01339 Person-Centered Planning Fidelity Checklist
F-01332 Predispositional Investigation Report (PDI)
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs
F-01345 Special Care Environment Working Document
F-01346 Behavior Monitoring Record-Model
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-00202 Individual Service Plan - Community Recovery Services (CRS)
F-00596a PPS Mental Health Deskcard
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-00660A Client Rights Office Consult Question
F-00588 PPS Alcohol and Other Drug Abuse Module
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results
F-00596 PPS Mental Health Module
F-00085 Power of Attorney for Health Care
F-00060 Declaration to Physicians (Living Will)
F-01619 OARS Welcome Letter
F-01628 OARS Enrollment Letter
F-82006 Employment Application and Resume

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Last Revised: July 28, 2017