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-11088 | Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) | DMS | None |
| F-00596a | PPS Mental Health Deskcard | DCTS | None |
| F-10190 | Medicaid Issuer of Annuity - Notice of Obligation | DMS | None |
| F-01619 | OARS Welcome Letter | DCTS | None |
| F-00467 | Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 | DQA | None |
| F-44236 | Pertussis Case Report | DPH | None |
| F-02106D | Adult Day Care Center – New Provider Certification Application Checklist | DQA | None |
| F-10096 | Community Spouse Asset Share | DMS | None |
| F-00989P | Individualized Family Service Plan Team Signature (IFSP) | DMS | None |
| F-00312 | Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation | DCTS | None |
| F-02400A | Client Transfer: Assisted Living Facility Capability | DQA | None |
| F-01337 | Worksheet for Determination of Parental Payment Limit for CLTS | DMS | None |
| F-00905 | Tuberculosis Infection (LTBI) Initial Request for Medication | DPH | None |
| F-22018i | HSRS Long-Term Support Module Desk Card | DES | None |
| F-01199 | Optional School-Based Services Activity Medication Administration | DMS | None |
| F-82009TC | Confidential Information Release Authorization for Transportation Complaint Research | DMS | None |
| F-02816 | Annual Review for FoodShare Employment and Training (FSET) Program | DMS | None |
| F-16026 | Prosecution Diversion Agreement | DMS | None |
| F-02106 | Adult Day Care Center – Applicant Compliance Statement | DQA | None |
| F-02721A | Notice of Delay in Functional Eligibility Determination | DPH | None |
| F-01067 | HealthCheck Your Child's Speech and Hearing | DMS | None |
| F-13025 | BadgerCare Plus Premium Employer Wage Withholding and Instructions | DMS | None |
| F-01442K | IRIS Program Disenrollment Letter - Policy Noncompliance | DMS | None |
| F-62026 | Report of Hours Worked - Nurse Aide / Evening | DQA | None |
| F-62645B | Drug Repository Program: Donation Record | DQA | None |
| F-11042 | Prior Authorization Amendment Request | DMS | None |
| F-01805 | Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse | DQA | None |
| F-00547 | Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 | DQA | None |
| F-45010F | Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) | DPH | None |
| F-10150A | Your Rights and Responsibilities for Health Care | DMS | None |
| F-01631 | ADRC Call Summary Sheet | DPH | None |
| F-00381 | Outpatient Mental Health Clinic Certification Withdrawal Checklist | DQA | None |
| F-44001 | Legal Notice: Required Immunizations for Admission to Wisconsin Schools | DPH | None |
| F-02502 | Vaccine for Adults (VFA) Community Outreach | DPH | None |
| F-00634B | Records Access Log, Birth to 3 Program | DMS | None |
| F-25614 | Conditional Release Rules and Conditions | DCTS | None |
| F-82009V | Confidential Information Release Authorization: Rehabilitation Review | OLC | None |
| F-01204E | Letter – IRIS Program Notice of Action – Functional Eligibility | DMS | None |
| F-00116 | Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement | DPH | None |
| F-00250 | Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use | DMS | None |
| F-00054D | Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff | DPH | None |
| F-01268 | Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility | DCTS | None |
| F-21072 | Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting | DMS | None |
| F-01168 | Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases | DMS | None |
| F-62696 | Student Nurse / Graduate Nurse Verification | DQA | None |
| F-13168 | Wisconsin SeniorCare HIPAA Privacy Restriction Request | DMS | None |
| F-02119 | Nurse Aide Training Program – Classroom / Laboratory Specifications | DQA | None |
| F-01009B | Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older | DMS | None |
| F-62430 | Community Based Residential Facility (CBRF) Residents' Rights Complaint Report | DQA | None |
| F-02716 | Authorization to Allocate Elder Benefit Specialist Funding to the Aging and Disability Resource Center | DPH | None |
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Last Revised: March 23, 2021
