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-01408 Asthma Control Summary DPH
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-02057 ADRC Authorization for the Release of Confidential Information DPH
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-62594 Notice of Substantial Change Feeding Assistant Training Program DQA
F-02500 Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care DPH
F-02026 Ethnicity and Race Selection DPH
F-16038 Administrative Disqualification Hearing Notice DMS
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA
F-02702 Pre-Release Enrollment Agreement DPH
F-01068G General Pediatric Clinic - 15 Month Visit DMS
F-02046 IRIS Financial Projections Template DMS
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day DQA
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request DMS
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources DPH
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request DMS
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS
F-02109D CBRF – New Provider Licensure Application Checklist DQA
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-44024A WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women DPH
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP) DMS
F-05282 Wisconsin Divorce Certificate Application DPH
F-02403 Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment DPH
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-21225A Program Participation System (PPS): B-3 Module DMS
F-80142 Collections Delegation Application DES
F-02475 Hand Hygiene Observations DPH
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-02605A HCBS Settings Rule: Heightened Scrutiny Settings Review – Evidentiary Document Checklist DMS
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS
F-60795 Community Based Residential Facility (CBRF) Fire Inspection DQA
F-01601C DCTS Summary Line item Budget: Condensed DCTS
F-00805 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents DMS
F-01749 Prior Authorization Drug Attachment for Hypoglycemics, Insulin – Long-Acting DMS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-00533 Partnership Programs — Enrollment DPH
F-45007 Certificate of Disposition of Materials DPH
F-01588 Application for Available Beds DMS
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-02491 FoodShare Buy and Make Food Separately DMS
F-43009 Diabetes Emergency Action Plan DPH
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bed-Hold Days DMS

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Last Revised: March 23, 2021