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-45021 Generally Licensed Device Inspection by Mail DPH
F-01628 OARS Enrollment Letter DCTS
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) DQA
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-00989L Summary of Services (IFSP) DMS
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS
F-82009V Confidential Information Release Authorization: Rehabilitation Review OLC
F-01314 IRIS Program Employment Checklist DMS
F-21334 Encounter New User Request DMS
F-80479 Audit Confirmation Request DES
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-00044 User Agreement for System Access DES
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program DMS
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo DMS
F-16022 Social Security Number Referral DMS
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications DQA
F-01062 HealthCheck Adolescent Review DMS
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-02716 Authorization to Allocate Elder Benefit Specialist Funding to the Aging and Disability Resource Center DPH
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis DMS
F-00842 Pharmacy Services Lock-In Program - Program Summary DMS
F-62019 License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses DMS
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-02538A CLTS Provider Cost-Based Outlier DMS
F-10141 Wisconsin Funeral and Cemetery Aids Program Application DMS
F-01601A CST Summary Line Item Budget DCTS
F-02784 PASRR 30-Day Information Required for PASRR Exemption Letter Request DCTS
F-16023 Striker Evaluation DMS
F-02122 Opioid Crisis State Targeted Response Program Funding Request DCTS
F-01063 HealthCheck Family History DMS
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-02715 ADRC Client Tracking System Waiver Request DPH
F-02287 Vaccine Return - Request for Authorization to Return DPH
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification DPH
F-62022A Instructions for Report of Hours Worked and Resident Census Forms DQA
F-02634 Adult Day Care (ADC) Initial Survey Checklist DQA
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure DMS
F-00543A File Review Checklist DMS
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-02541 Wisconsin Birth Defects Condition Nomination DPH
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS
F-01601B ISP Line Item Detail Budget DCTS
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years DMS
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) DPH
F-02466 MCO Appeal Log for Family Care, Family Care Partnership, and PACE Programs DMS

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Last Revised: March 23, 2021