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 Title Division Other Locationsort descending
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP) DMS
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-01309 IRIS Program Orientation and Enrollment Checklist DMS
F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook DCTS
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events DPH
F-02774 Prenatal Care Coordination Postpartum Assessment Tool DPH
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-00021 HealthCheck Referral DMS
F-01186 Wisconsin Chronic Renal Disease Program Application DMS
F-80130 Financial Information  DES
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement DMS
F-02725 Application for COVID Connect Collection Site OS
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35 DQA
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-02643 Student Nurse Aide Skills Checklist DQA
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
F-42014 Acuity Index DPH
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04 DQA
F-45003 Occupational Exposure Record Per Monitoring Period DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-10137 Medicaid Change Report DMS
F-01586 Medical Stockpile Access Request DPH
F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications DPH
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents DMS
F-01413 Post-Assessment Questionnaire DPH
F-20572 Request for State Public Funding for Non-Residents DCTS
F-02067 Women, Infants, and Children (WIC) Staff Training Record DPH
F-01145 Wisconsin Hemophilia Home Care Program Residency Verification DMS
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide DQA
F-00780 Options Counseling Tip Card DPH
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-02068 Request to Establish a Children's COP Risk Reserve DMS
F-00987 EMS Service Operational Plan, Advanced Skills Addendum (Basic) DPH
F-62316 Hospice Patient Rights DQA
F-02603 Request for a Temporary Waiver of MAPP Premium DMS
F-00123 Wisconsin Declaration of Domestic Partnership Application DPH
F-11129A Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions DMS
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review DPH
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-02110C RCAC: New Provider Certification / Registration Application DQA
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services DCTS


Last Revised: March 23, 2021