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-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters DPH
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-02110B RCAC: Established Provider Certification / Registration Application Checklist DQA
F-01626 OARS Facility Checklist DCTS
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months DMS
F-02494 ForwardHealth Prior Authorization Speech-Generating Device Skills and Needs Profile Attachment DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination DPH
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice DMS
F-01556C IRIS Program Cost Share Repayment Plan Letter DMS
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-44764 Do Not Resuscitate Bracelet - Electronic Format DPH
F-01352 Background Check Appeal Request - IRIS Program DMS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate DMS
F-01999B Senior Companion Program: State Match Funding Application DPH
F-01205B IRIS Participant Education: Budget Amendments DMS
F-01407 Checklist (Asthma Care and Environmental Strategies) DPH
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-02111 Assisted Living – Fit and Qualified Application for Community-Based Residential Facilities and Adult Family DQA
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs DQA
F-02749 CLTS Exceptional Expense Notification DMS
F-00004 Health and Employment Counseling Application DMS
F-02034 Aging/ADRC Integration Funding Budget Worksheet DPH
F-00633 Notice and Consent for Screening DMS
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-00315D Written Prior Notice - Additional Assessment Recommended DMS
F-13073 Compound Drug Claim DMS
F-62092 Hospital Certificate of Approval Application DQA
F-11054 Prior Authorization / Enteral Nutrition Formula Attachment (PA/ENFA) DMS
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter DMS
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-02587 Children's Long-Term Support (CLTS) Waiver Program Deciding Together Implementation Planning Tool DMS
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-01648 Coverdell Stroke Care Partner Agreement DPH
F-44016 Asbestos Occupant Protection Plan DPH
F-02109A CBRF – Established Provider Licensure Application DQA
F-05260 Letter of Non-Marriage Application DPH
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP) DMS
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH
F-02436 Testing Questionnaire (AIDS/HIV) DPH
F-01309 IRIS Program Orientation and Enrollment Checklist DMS
F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook DCTS
F-21189 Rights of Detention DCTS
F-25393A Petition for Supervised Release DCTS
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-02805 Attestation for Use of Standing Prescription Order (Dr. Ryan Westergaard, Chief Medical Officer and State Epidemiologist), for trained personnel to collect and/or analyze specimens for COVID-19 testing CRT
F-00913 Annual Survey of Nursing Homes DQA

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Last Revised: March 23, 2021