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 Location
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance DCTS
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-01415 IRIS Adult Family Home Taxable Income Information DMS
F-81020E Confidentiality and Non-Disclosure Acknowledgement: Volunteer (Food Pantry) DMS
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11 DQA
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-62287 Hospice Complaint Report DQA
F-02086 Histoplasmosis Case Worksheet DPH
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-02851 Equipment List Out of Hospital Scenario DPH
F-05282 Wisconsin Divorce Certificate Application DPH
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01293D Participant Fiscal Employer Agent (FEA) Transfer Checklist DMS
F-01389 MHSIP Adult Satisfaction Survey DCTS
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-25527 Request for Increased Contract Allocation DCTS
F-01556C IRIS Program Cost Share Repayment Plan Letter DMS
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination DPH
F-16023 Striker Evaluation DMS
F-01409 Client Information Intake DPH
F-02436A PrEP Questionnaire DPH
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 DQA
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-62441 Report of Hours Worked - Other Direct Care Nurse Aide / Evening DQA
F-01729 Nonprobate Asset / Property Disclosure DMS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) DPH
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review DPH
F-02721A Notice of Delay in Functional Eligibility Determination DPH
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-01586 Medical Stockpile Access Request DPH
F-02605 Home and Community-Based Services (HCBS) Settings Rule DMS
F-01016 ForwardHealth Provider Suggestion DMS
F-19002 Request to Reduce QUEST Card Balance DMS
F-01389B MHSIP Family Satisfaction Survey DCTS
F-02470 IRIS Noncompliance Statement and Corrective Action Plan DMS
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-62579 Post Survey Questionnaire DQA
F-02112 2017 Community Support Program (CSP) Survey Worksheet DCTS
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS
F-45032 License, Permit or Registration - Radiation Only DPH
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-00036 Power of Attorney for Finance and Property DPH
F-01203 IRIS Provider Education – Health and Safety – Incident Reporting DMS
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS


Last Revised: March 23, 2021