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 Numbersort descending Title Division Other Location
F-00004 Health and Employment Counseling Application DMS
F-00004A Health and Employment Counseling - I Think I Need More Time DMS
F-00004B Health and Employment Counseling - I Have Reached Employment DMS
F-00017 Blood Lead Lab Reporting DPH
F-00020 Drug Addition Review Request DMS
F-00021 HealthCheck Referral DMS
F-00023 Case Management Agency Self-Audit Checklist DMS
F-00027 CSAS Standards Recertification Application - DHS 75.03 DMS
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-00036 Power of Attorney for Finance and Property DPH
F-00039 Asbestos Course Accreditation - Initial DPH
F-00040 Asbestos Course Accreditation - Renewal DPH
F-00041 Asbestos Project Notification DPH
F-00043 Communication to Local Educational Agency Regarding Child Referral DMS
F-00044 User Agreement for System Access DES
F-00046 Family Care Program — Enrollment DPH
F-00047 Designated Asbestos Coordinator DPH
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) DPH
F-00049 Asbestos Principal Instructor Application DPH
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget DPH
F-00052B Cares Data Access and Use Agreement / Designation of Cares Security and Data Exchange Coordinator DPH
F-00052C Organizational Transition for Dementia Care Specialist DPH
F-00053 Notice of Intent to Submit an Application (ADRC) DPH
F-00054 Request for Waiver of Education / Experience Requirements (ADRC) DPH
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 DPH
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-00060 Declaration to Physicians (Living Will) DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine DMS
F-00086 Authorization for Final Disposition DPH
F-00098 Summary of Information Letter DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-00101 Authorization to Request Birth Records DMS
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement DPH
F-00107 Self-Employment Income Report DMS
F-00114 EMS Service Director License Proxy for Individuals DPH
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument DCTS
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement DPH
F-00119 Personal Care Agency Application for Approval DQA
F-00123 Wisconsin Declaration of Domestic Partnership Application DPH
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement DMS
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency DQA
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate DMS
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DMS
F-00154 Wisconsin Consultative Examination Inquiry DMS

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Last Revised: March 23, 2021