Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Number Title Division Other Locationsort descending
F-44257 Wisconsin Immunization Record Card DPH
F-10112 Medicaid Disability Application DMS
F-10076 SeniorCare Application DMS
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-16104 Local Agency Customer Feedback DMS
F-00780 Options Counseling Tip Card DPH
F-82009AA Confidential Information Release Authorization - Katie Beckett Program DMS
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application DMS
F-10137 Medicaid Change Report DMS
F-49357 Personal Diabetes Care Record DPH
F-82009II WIC Confidential Information Release Authorization DPH
F-43016 Prevent Heart Disease & Stroke Wallet Card DPH
F-40054 Confidential Birth Defects Registry Report DPH
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671 DQA
F-13038 Notice of Intent to File a Lien DMS
F-69260 Resident Census and Conditions of Residents CMS-672 DQA
F-44702 Vaccine Administration Record DPH
F-10182 BadgerCare Plus Application Packet DMS
F-69312 Surveyor Notes Worksheet CMS-807 DQA
F-04020 Student Immunization Record - This form is intended for schools DPH
F-44089 Wisconsin WIC Checks Accepted Here - Stickers DPH
F-10183 Information Change Report DMS
F-05103 Facts About Your Child's Birth Certificate DPH
F-04020L Student Immunization Record, Long DPH
F-44727 WIC Vendor Training Proof DPH
F-01313 Register to Reschedule Lead (Pb) Certification Exam DPH
F-01112 HealthCheck Verification Card DMS
F-00888 ADRC Action Plan DPH
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-62062 Hospice License Application DQA
F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model DMS
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request DMS
F-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request DMS
F-12029 Managed Care Disenrollment Request DMS
F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice DMS
F-12025 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request DMS
F-45025 Patient Questionnaire DPH
F-47236 Operations and Maintenance Certificate DPH
F-47242 Asbestos Certification Application DPH
F-47219 Agent Change Sheet DPH
F-47020 Sink Requirements DPH
F-44757 WIC Farmer's Market Contract For Farmers DPH
F-40058 Verification of Transfer of USDA Commodities DPH
F-40060 The Emergency Food Assistance Program Commodities Inventory Report DPH
F-44755 WIC Farmers' Market Nutrition Program DPH
F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey DPH
F-45038 Wisconsin Mercury Exposure Study DPH
F-47198 Noise Exposure Sampling Sheet DPH


Last Revised: March 26, 2019