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-25904 Admission to Caseload - Revocation DCTS
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC DCTS
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC DCTS
F-26100 Client Rights Limitation or Denial Documentation DCTS
F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement DCTS
F-29314 COP Declaration of Income and Assets, and State Residency DPH
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH
F-40028 Participant Determination Letter DPH
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-40041 Certification and Food Package Pick-Up DPH
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training DPH
F-40054 Confidential Birth Defects Registry Report DPH
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers DPH
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program DPH
F-40058 Verification of Transfer of USDA Commodities DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-40060 The Emergency Food Assistance Program Commodities Inventory Report DPH
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-40085 WIC Program Notice of Ineligibility DPH
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-40096 eWIC Program Repayment Agreement DPH
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-40117 Abortion Information Provision Certification DPH
F-40303 Early Childhood Caries Prevention Screening DPH
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy DPH
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement DPH
F-42000 Vaccine Order DPH
F-42001 Tuberculosis Suspect Case Data DPH
F-42010 Interjurisdictional Tuberculosis Notification DPH
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up DPH
F-42014 Acuity Index DPH
F-42016 Authorization for Release of Confidential HIV Test Results DPH
F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications DPH
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-43009 Diabetes Emergency Action Plan DPH
F-43013 Diabetes Medical Management Plan DPH
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral DPH
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC) DPH
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) DPH
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation DPH
F-43026 Wisconsin Donor Registry User Access Request DPH
F-44000 Tuberculosis Disease Initial Request for Medication DPH
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH

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Last Revised: March 23, 2021