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Official DHS Forms Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions. When you are searching for a document, enter the number or a portion of the title in the search box below. To narrow your search results even more, place quotation marks (" ") around search terms.

If you are looking for an informative document, visit our Informative Documents and Publications Library. If you need a file in another file format or can't find what you are looking for here, reach out to the Digital Communications Team at dhsfmorder@dhs.wisconsin.gov. You can typically expect a response within 1-2 business days.

Assigned Number Title Division Language Release Date File Type Available to Order
F-44257 Wisconsin Immunization Record Card DPH English 11/2022 PDF Yes
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH English 05/2019 PDF No
F-02487CM Wisconsin Immunization Registry (WIR) Record Release Authorization, Chinese (Simplified) DPH Chinese (Simplified) 05/2019 PDF No
F-02487HI Wisconsin Immunization Registry (WIR) Record Release Authorization, Hindi DPH Hindi 05/2019 PDF No
F-02487H Wisconsin Immunization Registry (WIR) Record Release Authorization, Hmong DPH Hmong 05/2019 PDF No
F-02487SO Wisconsin Immunization Registry (WIR) Record Release Authorization, Somali DPH Somali 05/2019 PDF No
F-02487S Wisconsin Immunization Registry (WIR) Record Release Authorization, Spanish DPH Spanish 05/2019 PDF No
F-05102 Wisconsin Immunization Registry Opt-out Request DPH English 07/2019 PDF Yes
F-03037 Wisconsin Lead-in Water Testing and Remediation (WTR) Initiative DPH English 05/2022 PDF No
F-10144 Wisconsin Life Insurance Inquiry DMS English 05/2019 Word No
F-05281 Wisconsin Marriage Certificate Application DPH English 12/2023 PDF No
F-05281S Wisconsin Marriage Certificate Application, Spanish DPH Spanish 01/2024 PDF No
F-11048 Wisconsin Medicaid - Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS English 02/2009 PDF No
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS English 08/2019 PDF No
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS English 08/2019 Word No
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS English 09/2019 Word No
F-01003 Wisconsin Medicaid Certification of Public Expenditures DMS English 07/2008 PDF No
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS English 04/2019 PDF No
F-11079A Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More Than 50 Beds)Rural Health Clinics Completion Instructions DMS English 07/2017 PDF No
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS English 08/2016 Word No
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS English 08/2016 Word No
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS English 12/2010 Word No
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS English 12/2010 PDF No
F-01009AH Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Hmong DMS Hmong 12/2010 PDF No
F-01009AH Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Hmong DMS Hmong 12/2010 Word No
F-01009AS Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Spanish DMS Spanish 12/2010 Word No
F-01009AS Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Spanish DMS Spanish 12/2010 PDF No
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS English 12/2010 Word No
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS English 12/2010 PDF No
F-01009BH Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Hmong DMS Hmong 12/2010 Word No
F-01009BH Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Hmong DMS Hmong 12/2010 PDF No
F-01009BS Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Spanish DMS Spanish 12/2010 PDF No
F-01009BS Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Spanish DMS Spanish 12/2010 Word No
F-10101 Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet DMS English 03/2024 PDF Yes
F-10101DA Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Dari DMS Dari (Afghan Persian) 03/2024 PDF No
F-10101H Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Hmong DMS Hmong 03/2024 PDF No
F-10101PA Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Pashto DMS Pashto 03/2024 PDF No
F-10101S Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Spanish DMS Spanish 03/2024 PDF No
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS English 08/2018 PDF No
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS English 07/2008 PDF No
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election DMS English 05/2023 Word No
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election DMS English 05/2023 PDF No
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness DMS English 08/2019 Word No
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness DMS English 08/2019 PDF No
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS English 02/2017 Word No
F-00180C Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation DMS English 09/2024 Word No
F-00180CS Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation, Spanish DMS Spanish 09/2024 Word No
F-03357 Wisconsin Medicaid Provider Enrollment Waiver or Variance Request OIG English 01/2025 Word No
F-03263 Wisconsin Medicaid Provider Self-Audit Overpayment Report OIG English 01/2024 PDF No
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS English 10/2012 PDF No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised December 4, 2024