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-16026 Prosecution Diversion Agreement DMS
F-16028 Notice of FoodShare Overissuance DMS
F-16029 FoodShare Wisconsin Repayment Agreement DMS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-16031 Student Aid and Expense Worksheet DMS
F-16033 FoodShare Worksheet DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-16073 FoodShare Wisconsin Nonfinancial Worksheet DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-16104 Local Agency Customer Feedback DMS
F-19002 Request to Reduce QUEST Card Balance DMS
F-20009 Complaint Report DCTS
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation DPH
F-20389 DCTS Program Performance Report DCTS
F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool DMS
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection DPH
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request DPH
F-20572 Request for State Public Funding for Non-Residents DCTS
F-20582 Medicaid – Katie Beckett Program Application DMS
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS
F-20812 SSI-E Natural Residential Setting Application Checklist DMS
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals DCTS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program DMS
F-20920 Formula to Determine Amount of Income Available to Pay for Room & Board in Substitute Care DMS
F-20933 Court Order for Assessment DCTS
F-20934 Court Ordered Assessment and Plan Report DCTS
F-20934A Plan Recommendation DCTS
F-20935 Status Report to Court for Plan Compliance DCTS
F-20941 Informed Consent for Participation in Wisconsin's Money Follows the Person (MFP) Demonstration DMS
F-20942A Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet OPIB
F-20985 Participant Rights and Responsibilities Notification DMS
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-21059 Variance Request for Institution Respite DMS
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting DMS
F-21076 Informed Consent – Children's Long-Term Support Functional Screen DMS
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request DCTS
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers DPH

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Last Revised: March 23, 2021