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-80477 Canteen Operations Statement of Revenues / Expenses and Fund Equity Changes - GAAP Basis
F-80477A Canteen Operations Analysis of Cash - GAAP Basis
F-80477B Canteen Operations Balance Sheet - GAAP Basis
F-47247 Ambulance Attendant License/Permit Renew
F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-80122 Journal Voucher
F-80115 Operating Budget
F-44771AA Medicaid Targeted Case Management Face Sheet - Childhood Lead Poisoning
F-00020 Drug Addition Review Request
F-62019 License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD)
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY)
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB)
F-00917 Provider Enrollment Application Process
F-40058 Verification of Transfer of USDA Commodities
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency
F-80952 Contingency Plan - Health and Human Services Agencies
F-80952A Contingency Plan - DHS Regional Offices
F-00191A Certified Outpatient Clinic Request for a School Branch Office
F-44089 Wisconsin WIC Checks Accepted Here - Stickers
F-00233 Renewal Summary Letter
F-45038 Wisconsin Mercury Exposure Study
F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice
F-05027B Report of Naturalization
F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR)
F-05102 Wisconsin Immunization Registry Exclusion
F-00724 Contract Performance - Payment Bond Form
F-05021T Report of Legal Name Change - Tribal
F-69312 Surveyor Notes Worksheet CMS-807
F-47181 First Responder Certification Card
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication
F-05044 Cause of Death Amendment
F-80462 Capital Asset Summary
F-00017 Blood Lead Lab Reporting
F-00553 Professional & Occupational License Application & Affidavit
F-62296 Entrance Conference Checklist
F-47020 Sink Requirements
F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey
F-01215 National CLAS Standards Pledge
F-00653a Patient Data Import Training
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB)
F-47477 First Responder / Emergency Medical Technician Certificate / License
F-05022 Report of Adoption
F-01112 HealthCheck Verification Card
F-47198 Noise Exposure Sampling Sheet
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey
F-00191 Certified Outpatient Clinic Request for a Branch Office
F-10144 Life Insurance Inquiry

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Last Revised: May 22, 2018