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-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) DPH
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36 DQA
F-00754 Wisconsin Civil Service Request for Examination Accommodations DES
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-00476 CARES Automated Systems Access Request DMS
F-44019A Immunization Assessment DPH
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application DCTS
F-01710 Home Health Agency Initial Licensure Checklist DQA
F-01634 Workplace Wellness Grant Program Application DPH
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-02460 OBVI Bold Lined Paper DPH
F-05281 Wisconsin Marriage Certificate Application DPH
F-00219 Self-Employment Income Report: Farm Business DMS
F-16026 Prosecution Diversion Agreement DMS
F-02400A Client Transfer: Assisted Living Facility Capability DQA
F-16024 FoodShare Notice of Disqualification DMS
F-16025 Disqualification Consent Agreement DMS
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet DQA
F-00380 Outpatient Mental Health Clinic Certification Withdrawal DQA
F-16029 FoodShare Wisconsin Repayment Agreement DMS
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application DMS
F-00039 Asbestos Course Accreditation - Initial DPH
F-00040 Asbestos Course Accreditation - Renewal DPH
F-00703 Patient Side Training Report DPH
F-00049 Asbestos Principal Instructor Application DPH
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral DPH
F-02461 Tuberculosis (TB) Treatment Assistance Program - Special Request DPH
F-02462 Tuberculosis (TB) Treatment Assistance Enrollment and Agreement DPH
F-40041 Certification and Food Package Pick-Up DPH
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-21276A DCTS Coordinated Services Teams (CST) Grant / Contract Application Summary DCTS
F-01542 Notification of Required Drug Testing DMS
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP) DMS
F-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-00107 Self-Employment Income Report DMS
F-00086 Authorization for Final Disposition DPH
F-02324 Wisconsin’s American Sign Language Interpreter, SSP and CART Directory Sign-Up and/or Change Request DPH
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-02536 Nursing Home: Waiver or Variance Request DQA
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs DQA
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-02522 Supervised Release Individual Client Summary DCTS
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services DPH

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Last Revised: March 26, 2019