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 Numbersort ascending Title Other Location
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral
F-43016 Prevent Heart Disease & Stroke Wallet Card
F-43013 Diabetes Medical Management Plan
F-43009 Diabetes Emergency Action Plan
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications
F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications
F-42030 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) Vaccine
F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program
F-42024 Vaccine Fahrenheit Temperature Log
F-42023 Vaccine Celsius Temperature Log
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results
F-42017 Wisconsin Initial Refugee Health Assessment
F-42016 Authorization for Release of Confidential HIV Test Results
F-42014 Acuity Index
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up
F-42010 Interjurisdictional Tuberculosis Notification
F-42007 Mail Label 3 X 4 - Immunization Program
F-42002 Warning: Do Not Unplug Refrigerator - Label
F-42001 Tuberculosis Suspect Case Data
F-42000 Vaccine Order
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services
F-40310 Adult Oral Health Screening (PDF, 176 KB)
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB)
F-40303 Early Childhood Caries Prevention Screening
F-40123A Hearing Screening Postcard - English
F-40117 Abortion Information Provision Certification
F-40108 Retail Vendor Application Amendment WIsconsin Women, Infant, and Children (WIC) Program
F-40104 WIC Retail Vendor Annual Food Sales Survey
F-40098 Worksite Wellness Kit Survey and Request
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-40096 eWIC Program Repayment Agreement
F-40093 Annual ROSIE User Security and Confidentiality Agreement
F-40092 Physical Activity Zone
F-40085 WIC Program Notice of Ineligibility
F-40076 Women, Infants, and Children (WIC) Nutrition Program Income Statement
F-40075 Pedometer Walking Program
F-40074 Annual Physical Activity Record
F-40073 Monthly Physical Activity Sheet
F-40072 8 Week Activity Log
F-40071 Children's Physical Activity Chart
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs
F-40063 TEFAP / CSFP Commodities Complaint
F-40062 TEFAP / CSFP Commodity Loss Report
F-40060 The Emergency Food Assistance Program Commodities Inventory Report
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification
F-40058 Verification of Transfer of USDA Commodities

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Last Revised: May 22, 2018