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 Titlesort descending Other Location Language
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting English
F-20922 Determination of No Active Treatment (NAT) Rating English
F-01348 Determining the Weighted Care Management Rate-Direct Service Staff Worksheet CM-I (Model) (PDF, 37 KB) English
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool English
F-83271 DHS Website Feedback English
F-43009 Diabetes Emergency Action Plan (PDF, 122 KB) English
F-43013 Diabetes Medical Management Plan (PDF, 587 KB) English
F-16060C Disaster FoodShare Application – Puerto Rico Residents English
F-16105 Disaster FoodShare Notice of Decision English
F-02036 Disaster Response Interpreter Training Application English
F-16025 Disqualification Consent Agreement English
F-10187 Divestment Penalty and Undue Hardship Notice English
F-00728 Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix English
F-05282 Divorce Certificate Application - Wisconsin (PDF, 1.6 MB) English
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation English
F-62096A DQA Authority for Obtaining Provider Records Without Written Release (PDF, 59 KB) English
F-00020 Drug Addition Review Request English
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record English
F-62643 Drug Repository Program Notice of Participation or Withdrawal English
F-62645 Drug Repository Program Recipient Record English
F-05218 E-mail Notification Request For New Publication Release English
F-40303 Early Childhood Caries Prevention Screening (PDF, 117 KB) English
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP) English
F-01410 Education-Medication Summary - Part A English
F-01411 Education-Medication Summary - Part B English
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra English
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers English
F-00343 Eligibility Management (Income Maintenance) Policy Notification Sign-Up English
F-44763 Emergency Care - Do Not Resuscitate Order (DNR) English
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan English
F-00646 Emergency Medical Service Training Center - Training Eligibility Certification English
F-47482 Emergency Medical Service Training Center Certification Application (PDF, 84 KB) English
F-47489 Emergency Medical Services (EMS) Patient Care Worksheet (PDF, 620 KB) English
F-00567 Emergency Medical Services Complaint English
F-47255 Emergency Medical Services Funding Assistance Program Municipal Signature and Population Verification Page English
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment English
F-47463B Emergency Medical Techician (EMT) - Basic Operational Plan Components (PDF, 26 KB) English
F-47463D Emergency Medical Techician (EMT) - Intermediate Operational Plan Components (PDF, 26 KB) English
F-47463C Emergency Medical Techician (EMT) - Intermediate Technician Operational Plan Components (PDF, 721 KB) English
F-47472 Emergency Medical Techician (EMT) License / First Responder Certification Renewal Application English
F-47463E Emergency Medical Technician (EMT) - Paramedic Operational Plan Components (PDF, 27 KB) English
F-47464 Emergency Medical Technician - Basic IV Training Permit Application (PDF, 160 KB) English
F-47128 Emergency Medical Technician - Basic Training Permit Application (PDF, 711 KB) English
F-47125 Emergency Medical Technician - Intermediate Training Permit Application (PDF, 233 KB) English
F-47471 Emergency Medical Technician Verification of Licensure English
F-47141 Emergency Medical Technician-Paramedic Training Permit Application (PDF, 160 KB) English
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 English
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 English
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 English
F-01651 Employee Information (PDF, 967 KB) English

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Last Revised: July 28, 2017