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-00236 Request for a State Fair Hearing - MCO DMS
F-02491 FoodShare Buy and Make Food Separately DMS
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services DPH
F-44161 WIC Rights and Responsibilities DPH
F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) DPH
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bed-Hold Days DMS
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities DQA
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-01389 ROSI Adult Satisfaction Survey DCTS
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-22540 Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs OPIB
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS
F-80881 Profile ID Request (CARS) DES
F-02560 Assistive Technology Survey for Members, Participants, and Providers of Medicaid-Funded Long-Term Care Programs DMS
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-40098 Worksite Wellness Kit Survey and Request DPH
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-00123 Wisconsin Declaration of Domestic Partnership Application DPH
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-02559 Assistive Technology Survey for MCO and ICA Staff DMS
F-10112 Medicaid Disability Application DMS
F-80477A Canteen Operations Analysis of Cash - GAAP Basis DES
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-40096 eWIC Program Repayment Agreement DPH
F-82009II WIC Confidential Information Release Authorization DPH
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators DPH
F-45022 Application for Material License 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-02011 Fluoride Mouth Rinse Program Annual Report DPH
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography 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-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

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Last Revised: March 26, 2019