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-44000 Tuberculosis Disease Initial Request for Medication DPH
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program DMS
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program DMS
F-25527 Request for Increased Contract Allocation DCTS
F-01204D Letter – IRIS Program Notice of Action – Termination DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH
F-01264 Service Fund Application for Reimbursement DPH
F-20942A Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet OPIB
F-62692 Feeding Assistant Training Program Primary Instructor Application DQA
F-00978 Confirmation of Confidential Data Destruction - Wisconsin Cancer Reporting System (WCRS) DPH
F-01165 Newborn Report DMS
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys DCTS
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization DMS
F-62373 Resident Evacuation Assessment DQA
F-01389 MHSIP Adult Satisfaction Survey DCTS
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F02637 Requesting FSIA Access During COVID-19 Health Emergency DMS
F-00688 Referral to Wisconsin Birth to 3 Program DMS
F-01710 Home Health Agency Initial Licensure Checklist DQA
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-02538 Children’s Long-Term Support Waiver Program—Outlier Rate Request DMS
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels DPH
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications DQA
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report DQA
F-02716 Authorization to Allocate Elder Benefit Specialist Funding to the Aging and Disability Resource Center DPH
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis DMS
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines DMS
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-02538A CLTS Provider Cost-Based Outlier DMS
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 DQA
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility DMS
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-22571 Caretaker Supplement Application DMS
F-01229 WISEWOMAN Provider Assurances and Training Checklist DPH

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Last Revised: March 23, 2021