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-02763 | Acute Hospital Care at Home Program: Emergency Request for Approval | DQA | None |
| F-01302 | Weekly Driver's Vehicle Inspection Report | DMS | None |
| F-40117 | Abortion Information Provision Certification | DPH | None |
| F-01647 | Coverdell Emergency Medical Services (EMS) Partner Agreement | DPH | None |
| F-00165 | Civil Rights Compliance Letter of Assurance | OLC | None |
| F-02620 | Supervised Release (SR) Client Contact Request | DCTS | None |
| F-20817A | Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses | DMS | None |
| F-01427 | Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting | DMS | None |
| F-02499 | Nonresidential Group Supported Employment Site Survey | DMS | None |
| F-01200 | IRIS Program Cost Share Repayment Agreement | DMS | None |
| F-12025 | Wisconsin BadgerCare Plus HMO Enrollment Choice | DMS | Other |
| F-62645 | Drug Repository Program: Recipient Record | DQA | None |
| F-02341A | Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration | DMS | None |
| F-00942 | Meet Our "Henry" | DMS | None |
| F-10175 | Statement of Identity for Persons in Institutional Care Facilities | DMS | None |
| F-47477 | First Responder / Emergency Medical Technician Certificate / License | DPH | None |
| F-02026 | Ethnicity and Race Selection | DPH | None |
| F-00512 | Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 | DQA | None |
| F-02778 | Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply | CRT | None |
| F-01346 | Behavior Monitoring Record-Model | DPH | None |
| F-43025 | Document of Anatomical Gift Authorization for Organ and Tissue Donation | DPH | None |
| F-01626 | OARS Facility Checklist | DCTS | None |
| F-00236 | Request for a State Fair Hearing - MCO | DMS | None |
| F-02610B | Occupant Worksheet - Lead-Safe Homes Program Application | DPH | None |
| F-21336 | Consent for Exchange of Information with Local Educational Agency | DMS | None |
| F-01454D | IRIS Program Withdrawal Letter – Non Eligible Setting | DMS | None |
| F-02107C | Family Adult Day Care Center – New Provider Certification Application | DQA | None |
| F-01213 | Accessibility Assessment Request | DMS | None |
| F-13147 | Wisconsin Medicaid HIPAA Privacy Restriction Request | DMS | None |
| F-69260 | Resident Census and Conditions of Residents CMS-672 | DQA | Other |
| F-20933 | Court Order for Assessment | DCTS | None |
| F-01009B | Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older | DMS | None |
| F-11016 | Prior Authorization Physician Attachment (PA/PA) | DMS | None |
| F-62026 | Report of Hours Worked - Nurse Aide / Evening | DQA | None |
| F-83271 | DHS Website Feedback | OS | None |
| F-00545 | Emergency Outpatient Service Initial Certification Application - DHS 75.05 | DQA | None |
| F-02816 | Annual Review for FoodShare Employment and Training (FSET) Program | DMS | None |
| F-05029 | Request To Withdraw Voluntary Paternity Acknowledgement | DPH | Other |
| F-44151 | Acute and Communicable Disease Case Report | DPH | None |
| F-42014 | Acuity Index | DPH | None |
| F-00301 | 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application | DCTS | None |
| F-02655 | Maternal Mortality Review Team Community Member Application | DPH | None |
| F-00017 | Blood Lead Lab Reporting | DPH | None |
| F-22559 | Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors | DPH | None |
| F-00989C | Summary of Development Child’s Positive Social Emotional Skills (IFSP) | DMS | None |
| F-82009Y | Confidential Information Release Authorization - Testing Records | DCTS | None |
| F-13163 | Wisconsin SeniorCare HIPAA Privacy Accounting Request | DMS | None |
| F-83263 | Rehabilitation Review Application and Instructions | OS | None |
| F-21353 | CLTS One Time High-Cost Notification | DMS | None |
| F-01067 | HealthCheck Your Child's Speech and Hearing | DMS | None |
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Last Revised: March 23, 2021
