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-01314 | IRIS Program Employment Checklist | DMS | None |
| F-21334 | Encounter New User Request | DMS | None |
| F-02346 | Training Course Accreditation Application Lead Disciplines | DPH | None |
| F-80479 | Audit Confirmation Request | DES | None |
| F-02825 | Wisconsin Department of Health Services Stockpile Policy and Request | DPH | None |
| F-11134 | Personal Care Prior Authorization Provider Acknowledgement | DMS | None |
| F-02737 | COVID Impact Survey for Behavioral Health Providers – Prep | DCTS | None |
| F-01195 | Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo | DMS | None |
| F-16022 | Social Security Number Referral | DMS | None |
| F-01062 | HealthCheck Adolescent Review | DMS | None |
| F-62501 | Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing | DQA | None |
| F-01454F | IRIS Program Withdrawal Letter – Death | DMS | None |
| F-00842 | Pharmacy Services Lock-In Program - Program Summary | DMS | None |
| F-62019 | License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) | DQA | None |
| F-02610 | Owner-Occupied Properties - Lead-Safe Homes Program Application | DPH | None |
| F-11037 | Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) | DMS | None |
| F-44212 | School Report to the District Attorney | DPH | None |
| F-01196 | Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo | DMS | None |
| F-16023 | Striker Evaluation | DMS | None |
| F-01063 | HealthCheck Family History | DMS | None |
| F-62502 | Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing | DQA | None |
| F-01442i | IRIS Program Disenrollment Letter - Cancelled | DMS | None |
| F-00851 | AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification | DPH | None |
| F-62022A | Instructions for Report of Hours Worked and Resident Census Forms | DQA | None |
| F-82009F | Confidential Information Release Authorization: WISHIN | DCTS | None |
| F-11038 | Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) | DMS | None |
| F-00575 | Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) | DPH | None |
| F-00543A | File Review Checklist | DMS | None |
| F-45010B | Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) | DPH | None |
| F-02013 | TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets | DPH | None |
| F-10142 | Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant | DMS | None |
| F-01601B | ISP Line Item Detail Budget | DCTS | None |
| F-00367J | Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years | DMS | None |
| F-43024 | Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) | DPH | None |
| F-02288 | WisCaregiver Career Program: Registration Agreement | DQA | None |
| F-01481 | Marriage Record Amendment Request Officiant Affidavit | DPH | None |
| F-20987 | Authorized Representative Designation Medicaid Community Waiver Programs | DMS | None |
| F-02875 | Self-Care Assessment | DPH | None |
| F-00236B | Request for a State Fair Hearing - IRIS | DMS | None |
| F-25392 | Petition for Re-Examination | DCTS | None |
| F-00053 | Notice of Intent to Submit an Application (ADRC) | DPH | None |
| F-01257 | FoodShare Employment and Training (FSET) - Workshop Appointment | DMS | None |
| F-01204B | Letter – IRIS Program Notice of Action – Limit | DMS | None |
| F-20818 | Certification for SSI-E Exceptional Expense Supplement | DMS | None |
| F-00103 | Wisconsin Blood Lead Registry User Security and Confidentiality Agreement | DPH | None |
| F-01161 | Abortion Certification Statements | DMS | None |
| F-62680 | Home Health Agency (HHA): Clinical Record Review (State Only) | DQA | None |
| F-02778 | Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply | CRT | None |
| F-13164 | Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request | DMS | None |
| F-60947 | Adult Day Care Initial Certification Checklist | DQA | None |
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Last Revised: March 23, 2021
