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 ascending
F-02112 2017 Community Support Program (CSP) Survey Worksheet DCTS
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS
F-62657 Home Health Agency Contract Review Worksheet DQA
F-02764 Participant Fiscal Employer Agent (FEA) – Transfer Request DPH
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-02051 Wisconsin Donor Registry Enrollment DPH
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH
F-62319 Hospice Volunteer Program Review DQA
F-01316 Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet DMS
F-11130 Tribal and Out-of-State Federally Qualified Health Center Interim Report DMS
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review DPH
F-47463B EMT - Basic Operational Plan Components DPH
F-02596 Youth Crisis Stabilization Facilities (YCSF): Extension of Stay Authorization DCTS
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-02529 Accreditation Mentoring Program - Mentee Application DPH
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-00476 CARES Automated Systems Access Request DMS
F-44621 WIC Stock Price Survey DPH
F-10108 Medicaid Manual Notice for Cost of Care Contribution DMS
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares DMS
F-00321 OBVI Initial Interview Assessment DPH
F-40085 WIC Program Notice of Ineligibility DPH
F-02430 Statement About Immigration Status DMS
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH
F-01442C IRIS Program Disenrollment Letter – No Contact DMS
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS
F-20933 Court Order for Assessment DCTS
F-00004 Health and Employment Counseling Application DMS
F-01206 IRIS One-Time Expense Request DMS
F-01218 WISEWOMAN Client Consent DPH
F-16038 Administrative Disqualification Hearing Notice DMS
F-01729 Nonprobate Asset / Property Disclosure DMS
F-01068G General Pediatric Clinic - 15 Month Visit DMS
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA
F02761 Health Care Entity Staffing Request CRT
F-01989 Renewal Application – Individual Lead Disciplines DPH
F-02665 COVID-19: Assisted Living Change Worksheet DQA
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request DMS
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day DQA
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources DPH
F-02592 Rapid Test and Controls Inventory Log DPH
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-44024A WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women DPH

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Last Revised: March 23, 2021