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 Locationsort descending
F-01314 IRIS Program Employment Checklist DMS
F-21334 Encounter New User Request DMS
F-02346 Training Course Accreditation Application Lead Disciplines DPH
F-80479 Audit Confirmation Request DES
F-02825 Wisconsin Department of Health Services Stockpile Policy and Request DPH
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-02737 COVID Impact Survey for Behavioral Health Providers – Prep DCTS
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo DMS
F-16022 Social Security Number Referral DMS
F-01062 HealthCheck Adolescent Review DMS
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-01454F IRIS Program Withdrawal Letter – Death DMS
F-00842 Pharmacy Services Lock-In Program - Program Summary DMS
F-62019 License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA
F-02610 Owner-Occupied Properties - Lead-Safe Homes Program Application DPH
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-44212 School Report to the District Attorney DPH
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo DMS
F-16023 Striker Evaluation DMS
F-01063 HealthCheck Family History DMS
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification DPH
F-62022A Instructions for Report of Hours Worked and Resident Census Forms DQA
F-82009F Confidential Information Release Authorization: WISHIN DCTS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) DPH
F-00543A File Review Checklist DMS
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS
F-01601B ISP Line Item Detail Budget DCTS
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years DMS
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) DPH
F-02288 WisCaregiver Career Program: Registration Agreement DQA
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-02875 Self-Care Assessment DPH
F-00236B Request for a State Fair Hearing - IRIS DMS
F-25392 Petition for Re-Examination DCTS
F-00053 Notice of Intent to Submit an Application (ADRC) DPH
F-01257 FoodShare Employment and Training (FSET) - Workshop Appointment DMS
F-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement DPH
F-01161 Abortion Certification Statements DMS
F-62680 Home Health Agency (HHA): Clinical Record Review (State Only) DQA
F-02778 Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply CRT
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-60947 Adult Day Care Initial Certification Checklist DQA


Last Revised: March 23, 2021