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 Number Titlesort descending Division Other Location
F-22553A Free In-Service or Educational Training Request DPH
F-62496 Free-Standing Community-Based Residential Facility (CBRF) Plan Approval Application DQA
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs DMS
F-01068F General Pediatric Clinic - 12 Month Visit DMS
F-01068G General Pediatric Clinic - 15 Month Visit DMS
F-01068H General Pediatric Clinic - 18 Month Visit DMS
F-01068i General Pediatric Clinic - 24 Month Visit DMS
F-01068A General Pediatric Clinic - 3 to 4 Week Visit DMS
F-01068C General Pediatric Clinic - 4 Month Visit DMS
F-01068D General Pediatric Clinic - 6 Month Visit DMS
F-01068B General Pediatric Clinic - 6 to 8 Week Visit DMS
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-01068J General Pediatric Clinic - Preschool Visit DMS
F-01068L General Pediatric Clinic - Teenager Visit DMS
F-45021 Generally Licensed Device Inspection by Mail DPH
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS
F-01212 Grievance - IRIS Program DMS
F-47204 Hazard Summary Form DPH
F-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet DMS
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-00004B Health and Employment Counseling - I Have Reached Employment DPH
F-00004A Health and Employment Counseling - I Think I Need More Time DMS
F-00004 Health and Employment Counseling Application DMS
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-62500 Health Care Facility Fire Report DQA
F-01062 HealthCheck Adolescent Review DMS
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-01063 HealthCheck Family History DMS
F-01002 HealthCheck Individual Health History DMS
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-00021 HealthCheck Referral DMS
F-11285 HealthCheck Screener Affirmation OIG
F-01112 HealthCheck Verification Card DMS
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP) DPH
F-02242 Hepatitis A High-Risk Occupations Questionnaire DPH
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases DPH
F-13148 HIPAA Privacy Access Request DMS
F-13149 HIPAA Privacy Accounting Request DMS
F-13151 HIPAA Privacy Amendment Request DMS
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS
F-13146 HIPAA Privacy Revocation of Authorization DMS
F-02086 Histoplasmosis Case Worksheet DPH
F-01359 Historical Earnings Verification Request DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH


Last Revised: March 26, 2019