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-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
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-40054 Confidential Birth Defects Registry Report
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training
F-40044 Participant Agreement, Rights & Responsibilities
F-40041 Certification and Food Package Pick-Up
F-40040 Envelope - Vendor and Integrity Unit #9
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing
F-40028 Participant Determination Letter
F-40019 Affirmation of Identity, Residency, and/or Income
F-29323 Hardship Policy / Hidden Asset Policy
F-29322 Uniform Cost Sharing Plan - COP Cost-Share Worksheet 3
F-29321 COP Cost-Share Worksheet #2
F-29320 COP Cost-Share Worksheet #1 Instructions
F-29319 COP Cost-Share Worksheet
F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP
F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant
F-29315 Instructions: Declaration of Income and Assets and State Residency
F-29314 COP Declaration of Income and Assets and State Residency
F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement
F-26100 Client Rights Limitation or Denial Documentation
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC
F-25904 Admission to Caseload - Revocation
F-25614 Conditional Release Rules and Conditions
F-25527 Request for Increased Contract Allocation
F-25393 Petition for Conditional Release
F-25392 Petition for Re-Examination

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Last Revised: July 28, 2017