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-12024 Wisconsin Medicaid HMO Enrollment Choice DMS
F-02839 Letter: IRIS Individual Support and Service Plan (ISSP) Signature Request DMS
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services DMS
F-44323 WIC Stock Price Survey – Pharmacy Only DPH
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-02672 CLTS Waiver Sole Proprietor Registration DMS
F-00053 Notice of Intent to Submit an Application (ADRC) DPH
F-01345 Special Care Environment Working Document DPH
F-00989J Transition Plan - Turning 3 Years Old (IFSP) DMS
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-01219 WISEWOMAN Health History Assessment DPH
F-02432 IRIS Program HIPAA Breach and Unauthorized Disclosure Reporting DMS
F-21334 Encounter New User Request DMS
F-00703 Patient Side Training Report DPH
F-62318 Hospice Quality Assessment and Performance Improvement Review DQA
F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool DMS
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS
F-00380 Outpatient Mental Health Clinic Certification Withdrawal DQA
F-44824 Wisconsin Day Care Assessment DPH
F-45003 Occupational Exposure Record Per Monitoring Period DPH
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-02720 Family Caregiver Support Program Initial Evaluation DPH
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-05027B Report of Naturalization DPH
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa DMS
F-01319C IRIS Program – Denial of Enrollment Letter DMS
F-01184 Wisconsin Hemophilia Home Care Program Application DMS
F-01359 Historical Earnings Verification Request DMS
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs DQA
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP) DPH
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request DQA
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 DQA
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-02567 Prior Authorization / Residential Substance Use Disorder Treatment Attachment (PA/RSUD) DMS
F-00176 Civil Money Penalty Funds Project Proposal DQA
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-01601 DCTS Summary Line Item Budget DCTS
F-05260 Letter of Non-Marriage Application DPH
F-02110A RCAC: Established Provider Certification / Registration Application DQA
F-01204 Notice of Action—IRIS Program DMS
F-01361 ForwardHealth Provider Express Enrollment Change of Address DMS
F-01785 Letter - 40-Hour Health and Safety Assurance Policy Exception Request Denial DMS

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Last Revised: March 23, 2021