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 Locationsort descending
F-02768 COVID-19 Wasted Vaccine Record CRT
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA
F-13072 Noncompound Drug Claim DMS
F-02059 New Carrier Insurance Disclosure Onboarding DMS
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH
F-62069A Personal Care Agency Complaint Report DQA
F-02577 Proof of In-Kind Hours DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-01804 Appointment Results Wisconsin WIC Program DPH
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 DQA
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators DPH
F-02110A RCAC: Established Provider Certification / Registration Application DQA
F-10161 Statement of Citizenship and/or Identity DMS
F-01621 Smoking Cessation Data Collection DCTS
F-00385 Nurse Aide Training - Student Waiver Request DQA
F-44016 Asbestos Occupant Protection Plan DPH
F-02493 ForwardHealth Prior Authorization Speech-Generating Device Purchase Recommendation Attachment DMS
F-00989M Justification for Services Provided in Locations Other than Natural Environments (IFSP) DMS
F-03037 Wisconsin Lead-in Water Testing and Remediation (WTR) Initiative DPH
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH
F-02400B Client Transfer: Labels DQA
F-02919 Vendor Performance Report for Division of Medicaid Services (DMS) DMS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH
F-01309 IRIS Program Orientation and Enrollment Checklist DMS
F-21189 Rights of Detention DCTS
F-01185 Wisconsin Adult Cystic Fibrosis Program Application DMS
F-80479 Audit Confirmation Request DES
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-02107 Family Adult Day Care Center – Applicant Compliance Statement DQA
F-01013 Nurse Aide Training and Competency Test Reimbursement Request DMS
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-02500 Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care DPH
F-11317 Certification Criteria for Providers Express Enrollment of Pregnant Women in BadgerCare Plus OIG
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-00759 Business Associate Agreement: With Contract DES
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) DPH
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura DMS
F-01601B ISP Line Item Detail Budget DCTS
F-02505 Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 DQA
F-10130 Medicaid Presumptive Disability DMS
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs DMS
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program DMS
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA

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Last Revised: June 16, 2022