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-44158 WIC Application Brochure/Postcard
F-42014 Acuity Index
F-42010 Interjurisdictional Tuberculosis Notification
F-43009 Diabetes Emergency Action Plan
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program
F-43026 Wisconsin Donor Registry User Access Request
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up
F-43013 Diabetes Medical Management Plan
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment
F-44000 Tuberculosis Disease Initial Request for Medication
F-42016 Authorization for Release of Confidential HIV Test Results
F-43016 Prevent Heart Disease & Stroke Wallet Card
F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools
F-42017 Wisconsin Initial Refugee Health Assessment
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral
F-42030 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) Vaccine
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC)
F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications
F-42023 Vaccine Celsius Temperature Log
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC)
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications
F-42024 Vaccine Fahrenheit Temperature Log
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services
F-42000 Vaccine Order
F-42001 Tuberculosis Suspect Case Data
F-00533 PACE / Partnership Programs - Enrollment
F-02124 2016 Comprehensive Community Services (CCS) Program Survey Worksheet
F-02074 Medicare Other Coverage Discrepancy Report
F-02122 Opioid Crisis State Targeted Response Program Funding Request
F-01234 Explanation of Medical Benefits
F-62320 Hospice Survey Information
F-02112 2017 Community Support Program (CSP) Survey Worksheet
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys
F-25177 Statement of Probable Cause and Detention and Petition for Revocation
F-10076 SeniorCare Application
F-40303 Early Childhood Caries Prevention Screening
F-62319 Hospice Volunteer Program Review
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS
F-40041 Certification and Food Package Pick-Up
F-40071 Children's Physical Activity Chart
F-40108 Retail Vendor Application Amendment WIsconsin Women, Infant, and Children (WIC) Program
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-40092 Physical Activity Zone
F-40072 8 Week Activity Log
F-40117 Abortion Information Provision Certification


Last Revised: May 22, 2018