Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Location
F-00165C Funded Programs Checklist OLC
F-00165D Customer Service Population Analysis (CSPA) Data Chart OLC
F-00165E Limited English Proficiency (LEP) Customer Data Analysis Chart OLC
F-00165A Recipient Contact Information OLC
F-01700 Exception-to-Policy Request DPH
F-10182 BadgerCare Plus Application Packet DMS
F-44702 Vaccine Administration Record DPH
F-10101 Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet DMS
F-02118 Authorized Signer Designation for Access to PPS and FSIA DMS
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation DQA
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-01430 Prior Authorization Drug Attachment for Xyrem and Xywav DMS
F-02913 Intentional Health Care Program Violation Acknowledgement DMS
F-00165 Civil Rights Compliance Letter of Assurance OLC
F-44621 WIC Stock Price Survey DPH
F-44323 WIC Stock Price Survey: Pharmacy Only DPH
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions DPH
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-02818 Notice of Action: Child Found Not Eligible for the Children's Long-Term Support Waiver Program DMS
F-02907 Conditional Release/Opening Avenues to Reentry Success (CR/OARS) Monthly Housing Survey DCTS
F-02906 Authorization to Transfer Aging and Disability Services GPR Funding to Another Agency DPH
F-02430 Statement About Immigration Status DMS
F-22538 Consent to Photograph or Record and Use of Photographs/Recordings DCTS
F-44000 Tuberculosis Disease Initial Request for Medication DPH
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-10137 Medicaid Change Report DMS
F-10183 Information Change Report DMS
F-44727A WIC Vendor Proof of Training (printable) DPH
F-02436 Testing Questionnaire (AIDS/HIV) DPH
F-44727 WIC Vendor Proof of Training (online submission) DPH
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-02888 Aging & Disability Resource Center Annual Update Checklist DPH
F-02805 Attestation for Use of Standing Prescription Order (Dr. Ryan Westergaard, Chief Medical Officer and State Epidemiologist), for trained personnel to collect and/or analyze specimens for COVID-19 testing CRT
F-44161 WIC Rights and Responsibilities DPH
F-00905 Tuberculosis Infection (LTBI) Initial Request for Medication DPH
F-05024 Voluntary Paternity Acknowledgement DPH
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-00905A Tuberculosis Contact Window Treatment Initial Request for Medication DPH
F-02900 Checklist for Newly Hired Disability Benefit Specialists (DBS) DPH
F-02522 Supervised Release Individual Client Summary DCTS
F-44192 Child Care Immunization Record DPH
F-02892 County Crisis or APS Partner Portal Request DMS
F-05042 Fetal Death Worksheet DPH
F-02832 IRIS Performance Improvement Project (PIP) Proposal DMS
F-44257 Wisconsin Immunization Record Card DPH
F-02716 Authorization to Allocate Elder Benefit Specialist Funding to the Aging and Disability Resource Center (ADRC) DPH
F-01622 OARS Records Checklist DCTS
F-02741 Wisconsin Emergency Assistance Volunteer Registry (WEAVR): COVID-19 Staffing Request CRT
F-02704 Community Testing Support Program Application CRT


Last Revised: June 16, 2022