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 Other Location
F-10076 SeniorCare Application
F-40108 Retail Vendor Application Amendment WIsconsin Women, Infant, and Children (WIC) Program
F-40092 Physical Activity Zone
F-40072 8 Week Activity Log
F-40019 Affirmation of Identity, Residency, and/or Income
F-40117 Abortion Information Provision Certification
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-40073 Monthly Physical Activity Sheet
F-40028 Participant Determination Letter
F-40062 TEFAP / CSFP Commodity Loss Report
F-40096 eWIC Program Repayment Agreement
F-40074 Annual Physical Activity Record
F-00046 Family Care Program - Enrollment
F-40063 TEFAP / CSFP Commodities Complaint
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-40075 Pedometer Walking Program
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-40040 Envelope - Vendor and Integrity Unit #9
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS
F-40041 Certification and Food Package Pick-Up
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program
F-40071 Children's Physical Activity Chart
F-29323 Hardship Policy / Hidden Asset Policy
F-26100 Client Rights Limitation or Denial Documentation
F-02047 IRIS Financial Reporting Template
F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement
F-29314 COP Declaration of Income and Assets and State Residency
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC
F-25904 Admission to Caseload - Revocation
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC
F-01338 Children's Long-Term Support Parental Fee Declaration Form - Model
F-02306 Application for Telecommunication Assistance Program (TAP)
F-01939 Wisconsin Medicaid Waiver Provider Registration
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-02050 Coordinated Services Teams (CST) Final Expenditure Report
F-02000 ADRC/Aging System User: Access/Delete/Change
F-16014 Notice of Program Violation
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-25213 Admission to Caseload - Mental Health
F-24277 Informed Consent for Psychotropic Medication
F-62236 Hospice Clinical Record Review
F-25180 Order of Discharge Upon Expiration of Commitment
F-25614 Conditional Release Rules and Conditions
F-25206 Petition for Capias
F-25207 Order Granting Capias
F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI)


Last Revised: May 22, 2018