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 Division Other Location
F-47247 Ambulance Attendant License/Permit Renew DPH
F-47255 Emergency Medical Services Program Municipal Signature and Population Verification DPH
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments DPH
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-47463A First Responder Operational Plan Components DPH
F-47463B EMT - Basic Operational Plan Components DPH
F-47463C Intermediate Technician Operational Plan Components DPH
F-47463D Intermediate Operational Plan Components DPH
F-47463E Paramedic Operational Plan Components DPH
F-47464 Emergency Medical Technician - Basic IV Training Permit Application DPH
F-47470 Change of EMS Medical Director DPH
F-47471 Emergency Medical Technician Verification of Licensure DPH
F-47472 Emergency Medical Technician (EMT) License / First Responder Certification Renewal Application DPH
F-47477 First Responder / Emergency Medical Technician Certificate / License DPH
F-47478 First Responder / Emergency Medical Technician Application Electronic Addition to a Roster DPH
F-47479 Trauma Care Facility Classification Application DPH
F-47482 EMT Training Center Certification Application DPH
F-47489 EMS Patient Care Worksheet DPH
F-49357 Personal Diabetes Care Record DPH
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application DQA
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs DQA
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-60367 Community Advisory Committee Documentation DQA
F-60795 Community Based Residential Facility (CBRF) Fire Inspection DQA
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist DQA
F-60945 Adult Family Home Initial Licensure Application DQA
F-60947 Adult Day Care Initial Certification Checklist DQA
F-60953 Adult Family Home Fire Safety Guide DQA
F-62019 License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA
F-62022A Instructions for Report of Hours Worked and Resident Census Forms DQA
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-62024 Report of Hours Worked - Nurse Aide / Day DQA
F-62025 Report of Hours Worked - Registered Nurse / Evening DQA
F-62026 Report of Hours Worked - Nurse Aide / Evening DQA
F-62027 Report of Hours Worked - Registered Nurse / Night DQA
F-62028 Report of Hours Worked - Nurse Aide / Night DQA
F-62030 Resident Census DQA
F-62062 Hospice License Application DQA
F-62069 Home Health Agency Complaint Report DQA
F-62069A Personal Care Agency Complaint Report DQA
F-62092 Hospital Certificate of Approval Application DQA
F-62096A DQA Authority for Obtaining Provider Records Without Written Release DQA
F-62155 Living Unit Census Report DQA
F-62156 Living Unit Direct Care Staff Report - Day Shift DQA
F-62157 Living Unit Direct Care Staff Report - Evening Shift DQA
F-62158 Living Unit Direct Care Staff Report - Night Shift DQA
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day DQA
F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening DQA
F-62166 Report of Hours Worked - Licensed Practical Nurse / Night DQA

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Last Revised: March 26, 2019