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 Language
F-21365 Comprehensive Community Services Startup Outcomes - 2009 English
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 English
F-42007 Mail Label 3 X 4 - Immunization Program English
F-62023 Report of Hours Worked - Registered Nurse / Day English
F-45020 Cumulative Occupational Exposure History (PDF, 149 KB) English
F-05043 Notice of Removal - Corpse (Hospital, Nursing Home, Hospice) English
F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671 English
F-45029i Instructions For School Food Safety Plan English
F-44236 Pertussis Case Report (PDF, 292 KB) English
F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 English
F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) English
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices English
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record English
F-43006 Health Care Facility Assurance for J-1 Visa Waiver Applications (PDF, 653 KB) English
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure (PDF, 168 KB) English
F-47181 First Responder Certification Card English
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint (PDF, 157 KB) English
F-47228 Report of Enforcement Methods English
F-00276 Behavioral Health Services Renewal Certification Application - DHS 94 and 92 English
F-44756 Wisconsin Tuberculosis Record Card English
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB) English
F-16073 FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) English
F-60367 Community Advisory Committee Documentation English
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography English
F-05027B Report of Naturalization English
F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR) English
F-44005 Visual Inspection of Registered Lead-Safe Property (PDF, 15 KB) English
F-62281 Care Level Change Notice English
F-00465 CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 English
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) English
F-80891 List of Expected Contracts English
F-00923 Reschedule Lead (PB) Certification Exam (PDF, 90 KB) English
F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) English
F-44828 Make Your Smile Count - Oral Screening English
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 English
F-10191 Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) English
F-42024 Vaccine Fahrenheit Temperature Log (PDF, 2.4 MB) English
F-00375 Yellow Fever Uniform Stamp Application (PDF, 32 KB) English
F-05102 Wisconsin Immunization Registry Exclusion English
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request (PDF, 158 KB) English
F-69308 Resident Review Worksheet CMS-805 English
F-47029 Monthly Swimming Pool Operation Report (PDF, 86 KB) English
F-00703 Patient Side Training Report (PDF, 86 KB) English
F-47217 Bed and Breakfast Inspection Report (PDF, 22 KB) English
F-01313 Register to Reschedule Lead (Pb) Certification Exam English
F-05021T Report of Legal Name Change - Tribal English
F-62652A Personal Care Agency Home Visit Guide English
F-00417 AODA Prevention Services Recertification Application - DHS 75.04 English
F-00012 CBRF Completion Documents (PDF, 18 KB) English
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization (PDF, 163 KB) English

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Last Revised: July 28, 2017