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 Division Other Location
F-10112 Medicaid Disability Application DMS
F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR) DPH
F-80477A Canteen Operations Analysis of Cash - GAAP Basis DES
F-00024 HSRS Core Summary Report OS
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-40096 eWIC Program Repayment Agreement DPH
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-82009II WIC Confidential Information Release Authorization DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices DPH
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope DPH
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-02011 Fluoride Mouth Rinse Program Annual Report DPH
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography DPH
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators DPH
F-45022 Application for Material License DPH
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) DPH
F-02530 Application for Wisconsin's Test of English Proficiency (TEP) and Board for Examination of Interpreters (BEI) DPH
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) DPH
F-45010D Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) DPH
F-45007 Certificate of Disposition of Materials DPH
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-45008 Application for Radioactive Material License for Medical Use DPH
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-45021 Generally Licensed Device Inspection by Mail DPH
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels DPH
F-22541 Incident Report - Medicaid Waiver Programs DMS
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application DQA
F-05034 Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. DPH
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement DQA

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Last Revised: March 26, 2019