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 Division Other Location
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities DQA
F-10097 Medicaid Income Allocation Notice DMS
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral OIG
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-01389B MHSIP Family Satisfaction Survey DCTS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-01389 ROSI Adult Satisfaction Survey DCTS
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-01219-pckt WISEWOMAN Integrated Office Visit Assessment Packet DPH
F-01221 WISEWOMAN Screening Activity DPH
F-22540 Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs OPIB
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS
F-04020L Student Immunization Record, Long DPH
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-00476 CARES Automated Systems Access Request DMS
F-80881 Profile ID Request (CARS) DES
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-00123 Wisconsin Declaration of Domestic Partnership Application DPH
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-02559 Assistive Technology Survey for MCO and ICA Staff DMS
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-02560 Assistive Technology Survey for Members, Participants, and Providers of Medicaid-Funded Long-Term Care Programs DMS
F-40098 Worksite Wellness Kit Survey and Request DPH
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH
F-10112 Medicaid Disability Application DMS
F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR) DPH
F-10182 BadgerCare Plus Application Packet DMS
F-00024 HSRS Core Summary Report OS
F-80477A Canteen Operations Analysis of Cash - GAAP Basis DES
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH
F-02558 Family Care Member Out-of-County Notification DMS
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-40096 eWIC Program Repayment Agreement DPH
F-82009II WIC Confidential Information Release Authorization DPH
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography DPH
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators DPH


Last Revised: March 26, 2019