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 Division Other Location
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities DQA
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-01389 ROSI Adult Satisfaction Survey DCTS
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS
F-22540 Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs OPIB
F-80881 Profile ID Request (CARS) DES
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-40098 Worksite Wellness Kit Survey and Request DPH
F-00123 Wisconsin Declaration of Domestic Partnership Application DPH
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-10112 Medicaid Disability Application DMS
F-80477A Canteen Operations Analysis of Cash - GAAP Basis DES
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH
F-82009II WIC Confidential Information Release Authorization DPH
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography DPH
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators DPH
F-45022 Application for Material License DPH
F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices DPH
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope DPH
F-02011 Fluoride Mouth Rinse Program Annual Report DPH
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-45010D Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) DPH
F-45007 Certificate of Disposition of Materials DPH
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-45008 Application for Radioactive Material License for Medical Use DPH
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) DPH
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) DPH
F-45021 Generally Licensed Device Inspection by Mail DPH
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels DPH
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement DQA
F-05034 Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. DPH

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Last Revised: March 26, 2019