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-01068F General Pediatric Clinic - 12 Month Visit DMS
F-62594 Notice of Substantial Change Feeding Assistant Training Program DQA
F-02567 Prior Authorization / Residential Substance Use Disorder Treatment Attachment (PA/RSUD) DMS
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist DMS
F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance DMS
F-62096A DQA Authority for Obtaining Provider Records Without Written Release DQA
F-11055 STAT-PA System Instructions DMS
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter DMS
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope DPH
F-02588 Financial Exploitation Tracking for Counties DPH
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-01649 Coverdell Stroke Champion Partner Agreement DPH
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-44017 Asbestos Application - Individual DPH
F-02109B CBRF – Established Provider Licensure Application Checklist DQA
F-05281 Wisconsin Marriage Certificate Application DPH
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) DMS
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook DCTS
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events DPH
F-02774 Prenatal Care Coordination Postpartum Assessment Tool DPH
F-80130 Financial Information  DES
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-01947 IRIS Participant Education Manual: Acknowledgement DMS
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-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-00114 EMS Service Director License Proxy for Individuals 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-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES) DMS
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS
F-60795 Community Based Residential Facility (CBRF) Fire Inspection DQA
F-00974 Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor DPH
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-01709 Case Management Service Plan DPH
F-00537 Community Substance Abuse Services (CSAS) Intervention Services Initial Certification Application - DHS 75.16 DQA
F-45007 Certificate of Disposition of Materials DPH
F-02536 Nursing Home: Waiver or Variance Request DQA
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-43009 Diabetes Emergency Action Plan DPH
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS

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Last Revised: March 23, 2021