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-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet DMS
F-00043 Communication to Local Educational Agency Regarding Child Referral DMS
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36 DQA
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-02260 Temporary QUEST Card Issuance Checklist DMS
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months DMS
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment DCTS
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-00044 User Agreement for System Access DES
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs DPH
F-01410 Education - Medication Summary - Part A DPH
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-02257 Temperature Excursion Incident Report - Wisconsin Vaccines for Children Program (VFC) DPH
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-62648A Personal Care Agency Sample Selection DQA
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-44215 Child Care Center Report to the District Attorney DPH
F-00950 Partnership Coverage Decision Letter DMS
F-62288 Care Level Determination Worksheet DQA
F-02667 Prior Authorization Drug Attachment for Headache Agents, Preventative Treatment DMS
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA) DMS
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline DMS
F-02607 Letter: 1-2 Bed Adult Family Home Recertification Application DMS
F-01627 OARS Provider Case Manager Checklist DCTS
F-00615 Change Project Report and Instructions DPH
F-10193 Undue Hardship Waiver Request DMS
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14 DQA
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program DPH
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS
F-01556 Medicaid Cost Share Letter - Initial DMS
F-00315B Transition Written Prior Notice DMS
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs DQA
F-01344 Strategies for Success with People Who Have Dementia-Behavior Analysis Worksheet-Model DPH
F-01427 Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting DMS
F-00154 Wisconsin Consultative Examination Inquiry DMS
F-22468 Application for Services Office for the Blind and Visually Impaired DPH
F-01201A IRIS Participant-Hired Worker Relationship Identification DMS
F-83263 Rehabilitation Review Application and Instructions OS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-02108 Adult Family Home – Applicant Compliance Statement DQA
F-62579 Post Survey Questionnaire DQA
F-02741 Wisconsin Emergency Assistance Volunteer Registry (WEAVR): COVID-19 Staffing Request DPH
F01454G IRIS Program Withdrawal Letter – Cancelled DMS
F-62645C Drug Repository Program: Destruction Record DQA
F-01068C General Pediatric Clinic - 4 Month Visit DMS


Last Revised: March 23, 2021