Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Numbersort descending Title Other Location Language
F-00004 Health and Employment Counseling Application English
F-00004A Health and Employment Counseling - I Think I Need More Time English
F-00004B Health and Employment Counseling - I Have Reached Employment (PDF, 19 KB) English
F-00005 Senior FMNP Agency Application to Participate English
F-00010 Risk Agreement - Participant English
F-00012 CBRF Completion Documents (PDF, 18 KB) English
F-00014 Ceiling Closure Inspection Checklist English
F-00015 Final Occupancy Inspection Checklist English
F-00016 Wall Closure Inspection Checklist English
F-00017 Blood Lead Lab Reporting English
F-00020 Drug Addition Review Request English
F-00021 HealthCheck Referral (PDF, 1.4 MB) English
F-00023 Case Management Agency Self-Audit Checklist (PDF, 1.5 MB) English
F-00024 HSRS Core Summary Report English
F-00027 CSAS Standards Recertification Application - DHS 75.03 English
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request English
F-00036 Power of Attorney for Finance and Property English
F-00039 Asbestos Course Accreditation - Initial (PDF, 83 KB) English
F-00040 Asbestos Course Accreditation - Renewal (PDF, 27 KB) English
F-00041 Asbestos Project Notification English
F-00042 Knowledge Journal English
F-00043 Communication to Local Educational Agency Regarding Child Referral English
F-00044 User Agreement for System Access English
F-00046 Family Care Program - Enrollment English
F-00047 Designated Asbestos Coordinator (PDF, 39 KB) English
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) English
F-00049 Asbestos Principal Instructor (PDF, 30 KB) English
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) English
F-00052 Aging and Disability Resource Center (ADRC) Application English
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget English
F-00052B CARES Data Access and Use Agreement (ADRC) English
F-00053 Notice of Intent to Submit an Application (ADRC) English
F-00054 Request for Waiver of Education / Experience Requirements (ADRC) English
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO English
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC English
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff English
F-00059 Outpatient Mental Health Clinic Application - DHS 35 English
F-00060 Declaration to Physicians (Living Will) English
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report English
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization English
F-00076 Variance Request - Wait List English
F-00079 Prior Authorization Drug Attachment for Modafinil and Nuvigil® English
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine English
F-00085 Power of Attorney for Health Care English
F-00086 Authorization for Final Disposition English
F-00098 Summary of Information Letter (PDF, 224 KB) English
F-00100 State Vital Records Cover Letter English
F-00101 Authorization to Request Birth Records English
F-00107 Self-Employment Income Report English
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) English


Last Revised: July 28, 2017