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-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-02544 Nursing Home Immediate Jeopardy (IJ) Removal Plan DQA
F-01573 Log of Ice Arena Air Quality DPH
F-02474 Active Tuberculosis (TB) Disease Follow-up Report DPH
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 DQA
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility DMS
F-22571 Caretaker Supplement Application DMS
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-01212 Grievance - IRIS Program DMS
F-01229 WISEWOMAN Provider Assurances and Training Checklist DPH
F-20389 DCTS Program Performance Report DCTS
F-02257 Temperature Excursion Incident Report - Wisconsin Vaccines for Children Program (VFC) DPH
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-62643 Drug Repository Program Notice of Participation or Withdrawal DQA
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-44215 Child Care Center Report to the District Attorney DPH
F-62236 Hospice Clinical Record Review DQA
F-02667 Prior Authorization Drug Attachment for Headache Agents, Preventative Treatment 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-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-00596a PPS Mental Health Deskcard DCTS
F-10190 Medicaid Issuer of Annuity - Notice of Obligation DMS
F-01354 OARS Individual Service Plan (ISP) DCTS
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 DQA
F-44236 Pertussis Case Report DPH
F-02519 Wisconsin Family Caregiver Support Programs Caregiver Needs Assessment DPH
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP) DMS
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs DQA
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS DMS
F-00905 Tuberculosis Infection (LTBI) Initial Request for Medication DPH
F-22018i HSRS Long-Term Support Module Desk Card DES
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research DMS
F-02835 Opening Avenues to Reentry Success (OARS2) Informed Consent for Mental Health Evaluation, Treatment, and Community Reintegration Services DCTS
F-16026 Prosecution Diversion Agreement DMS
F-02108 Adult Family Home – Applicant Compliance Statement DQA
F-02741 Wisconsin Emergency Assistance Volunteer Registry (WEAVR): COVID-19 Staffing Request DPH
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-02022 Claims Audit Report for Managed Long-Term Care MCOs DMS
F-62026 Report of Hours Worked - Nurse Aide / Evening DQA
F-02658 COVID-19 Testing DQA


Last Revised: March 23, 2021