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 Number Titlesort descending Division Other Location
F-19002 Request to Reduce QUEST Card Balance DMS
F-05029 Request To Withdraw Voluntary Paternity Acknowledgement DPH
F02637 Requesting FSIA Access During COVID-19 Health Emergency DMS
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-01885 Requesting State Trauma Registry Access DPH
F-00923 Reschedule Lead (PB) Certification Exam DPH
F-69260 Resident Census and Conditions of Residents CMS-672 DQA
F-62373 Resident Evacuation Assessment DQA
F-02282A Resident Relocation Plan DMS
F-02282 Resident Relocation Roster DMS
F-02634C Residential Care Apartment Complex (RCAC) Initial Survey Checklist DQA
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH
F-21189 Rights of Detention DCTS
F-62601 Rights of Home Health Agency Patients DQA
F-01558 Risk Agreement – IRIS Program DMS
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-11027 Rural Health Clinic Quarterly Cost Report DMS
F-11022 Rural Health Clinic Statistical Data DMS
F-45029 School Food Safety Program Inspection Report DPH
F-02828 School P-EBT Verification Letter Template DMS
F-04002 School Report to Local Health Department DPH
F-44212 School Report to the District Attorney DPH
F-00107 Self-Employment Income Report DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-01999B Senior Companion Program: State Match Funding Application DPH
F-10076 SeniorCare Application DMS
F-10080 SeniorCare Authorization of Representative DMS
F-00166 Service Delivery Discrimination Complaint DES
F-01264 Service Fund Application for Reimbursement DPH
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-62370 Significant Change in Health Screening Instrument Model Form DQA
F-01621 Smoking Cessation Data Collection DCTS
F-16022 Social Security Number Referral DMS
F-01345 Special Care Environment Working Document DPH
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification DMS
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster DMS
F-20812 SSI-E Natural Residential Setting Application Checklist DMS

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Last Revised: March 23, 2021