Skip to main content
Dot gov

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

HTTPS

Secure .gov websites use HTTPS
A lock () or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

Data Collection (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 form, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-02619 Template Language Managed Care Organizations are Required to Use in Grievance and Appeal Materials, Arabic DMS Arabic 02/2021 Word No
F-02619 Template Language Managed Care Organizations are Required to Use in Grievance and Appeal Materials, Hmong DMS Hmong 02/2021 Word No
F-21334 Encounter New User Request DMS English 02/2021 Word No
F-00237CM Appeal Request - MCOs - Inclusa, Chinese (Mandarin) DMS Chinese Mandarin 02/2021 Word No
F-00237L Appeal Request - MCOs - My Choice Wisconsin, Laotian DMS Laotian 02/2021 Word No
F-00237L Appeal Request - MCOs - Inclusa, Laotian DMS Laotian 02/2021 Word No
F-00237 Appeal Request - MCOs - Inclusa DMS English 02/2021 Word No
F-00237SO Appeal Request - MCOs - My Choice Wisconsin, Somali DMS Somali 02/2021 Word No
F-00237CM Appeal Request - MCOs - My Choice Wisconsin, Chinese (Mandarin) DMS Chinese Mandarin 02/2021 Word No
F-00237S Appeal Request - MCOs - Inclusa, Spanish DMS Spanish 02/2021 Word No
F-00237 Appeal Request - MCOs - My Choice Wisconsin DMS English 02/2021 Word No
F-00237SO Appeal Request - MCOs - Inclusa, Somali DMS Somali 02/2021 Word No
F-00237SE Appeal Request - MCOs - My Choice Wisconsin, Serbo-Croatian DMS Serbian (Serbo-Croatian) 02/2021 Word No
F-00237AR Appeal Request - MCOs - My Choice Wisconsin, Arabic DMS Arabic 02/2021 Word No
F-00237S Appeal Request - MCOs - My Choice Wisconsin, Spanish DMS Spanish 02/2021 Word No
F-00237AR Appeal Request - MCOs - Inclusa, Arabic DMS Arabic 02/2021 Word No
F-00237H Appeal Request - MCOs - Inclusa, Hmong DMS Hmong 02/2021 Word No
F-00237SE Appeal Request - MCOs - Inclusa, Serbo-Croatian DMS Serbian (Serbo-Croatian) 02/2021 Word No
F-00237H Appeal Request - MCOs - My Choice Wisconsin, Hmong DMS Hmong 02/2021 Word No
F-02663 Letterhead - EVV Personal Identification Number (PIN) DMS English 02/2021 HTML No
F-00780 Options Counseling Tip Card DPH English 02/2021 PDF No
F-02771 COVID-19 Ventilation Checklist DPH English 02/2021 PDF No
F-01619 OARS Welcome Letter DCTS English 02/2021 Word No
F-01628 OARS Enrollment Letter DCTS English 02/2021 Word No
F-02602 1-2 Bed Adult Family Home Certification Application Request DMS English 02/2021 Word No
F-44126 Antituberculosis Therapy Program Medication Refill Request DPH English 02/2021 PDF No
F-13509 Wisconsin Well Woman Program Provider Certification OIG English 01/2021 PDF No
F-01567 Letter: Request for Assignment of Medical Benefits DMS English 01/2021 Word No
F-02768 COVID-19 Wasted Vaccine Record DPH English 01/2021 PDF No
F-01661 Letter - Foster Care Termination, Family DMS English 01/2021 Word No
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG English 01/2021 PDF No
F-01661 Letter - Foster Care Termination, Youth DMS English 01/2021 Word No
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG English 01/2021 PDF No
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary - CBRF DMS English 01/2021 Word No
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary - 3-4 AFH DMS English 01/2021 Word No
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary - RCAC DMS English 01/2021 Word No
F-00236A Request for a State Fair Hearing - ADRC DPH English 01/2021 Word No
F-02721 Notice of Adverse Benefit Determination, Hmong DPH Hmong 01/2021 Word No
F-02721 Notice of Adverse Benefit Determination, Spanish DPH Spanish 01/2021 Word No
F-02721 Notice of Adverse Benefit Determination DPH English 01/2021 Word No
F-02721 Notice of Adverse Benefit Determination, Somali DPH Somali 01/2021 Word No
F-02721 Notice of Adverse Benefit Determination, Russian DPH Russian 01/2021 Word No
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA English 01/2021 Word No
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA English 01/2021 PDF No
F-11129B-H Tribal and Out-of-State Federally Qualified Health Center Cost Report Forms OIG English 01/2021 Excel No
F-11130 Tribal and Out-of-State Federally Qualified Health Center DMS English 01/2021 Excel No
F-02758 Federally Qualified Health Center Outstationed Enrollment Survey OIG English 01/2021 Excel No
F-11130 Tribal and Out-of-State Federally Qualified Health Center, Instructions DMS English 01/2021 PDF No
F-02758 Federally Qualified Health Center Outstationed Enrollment Survey, Instructions OIG English 01/2021 PDF No
F-02656 Federally Qualified Health Center Cost Report DMS English 01/2021 PDF No
Last revised April 13, 2023