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-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment DMS
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail DQA
F-00114 EMS Service Director License Proxy for Individuals DPH
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-02634 Adult Day Care Center (ADCC) Initial Survey Checklist DQA
F-00963 Children’s Long Term Support Reconciliation Packet DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program DMS
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program DPH
F-02544 Nursing Home Immediate Jeopardy (IJ) Removal Plan DQA
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS
F-01319C IRIS Program – Denial of Enrollment Letter DMS
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13 DQA
F-01345 Special Care Environment Working Document DPH
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page DMS
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) DPH
F-01218 WISEWOMAN Client Consent DPH
F-02857 YCSF Request for Exception-Age DCTS
F-02250 Quarterly Program Integrity Report OIG
F-02771 COVID-19 Ventilation Checklist CRT
F-00161 Caregiver Misconduct Reporting Requirements Worksheet DQA
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years DMS
F-01204 Notice of Action—IRIS Program DMS
F-16033 FoodShare Worksheet DMS
F-01068D General Pediatric Clinic - 6 Month Visit DMS
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs DQA
F-13066 Claim Refund DMS
F-02052 Asbestos Abatement Project Log DPH
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request DQA
F-02668 Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable DMS
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-02607 Letter: 1-2 Bed Adult Family Home Recertification Application DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-01210B Budget Amendment Annual Verification (BAAV) Request DMS
F-47463L Community EMS Operational Plan Components DPH
F-44012 Lead Abatement Notification DPH
F-02108D Adult Family Home – New Provider Licensure Application Checklist DQA
F-00989K Transition Plan - Other (IFSP) DMS
F-03032 Wisconsin Asthma-Safe Homes Program Environmental Services Provider Grant Application DPH
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet DQA
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH
F-62069 Home Health Agency Complaint Report DQA
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS

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Last Revised: June 16, 2022