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 ascending
F-12029 Managed Care Disenrollment Request DMS
F-62062 Hospice License Application DQA
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-05021 Report of Legal Name Change DPH
F-45029 School Food Safety Program Inspection Report DPH
F-44151 Acute and Communicable Disease Case Report DPH
F-45029i Instructions For School Food Safety Plan DPH
F-44161 WIC Rights and Responsibilities DPH
F-01336 Wisconsin Assessment of the Impaired Driver (WAID) and Other Substance Users DCTS
F-82009II WIC Confidential Information Release Authorization DPH
F-00888 ADRC Action Plan DPH
F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671 DQA
F-01112 HealthCheck Verification Card DMS
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-69260 Resident Census and Conditions of Residents CMS-672 DQA
F-44257 Wisconsin Immunization Record Card DPH
F-13038 Notice of Intent to File a Lien (Paper Only. Follow link to order paper copy.) DMS
F-69312 Surveyor Notes Worksheet CMS-807 DQA
F-05103 Facts About Your Child's Birth Certificate DPH
F-49357 Personal Diabetes Care Record DPH
F-40028 Participant Determination Letter DPH
F-82009AA Confidential Information Release Authorization - Katie Beckett Program DMS
F-16019A FoodShare Wisconsin Registration DMS
F-16019B FoodShare Wisconsin Registration Packet DMS
F-44702 Vaccine Administration Record DPH
F-04020 Student Immunization Record - This form is intended for schools DPH
F-10182 BadgerCare Plus Application Packet DMS
F-10183 Information Change Report DMS
F-44089 Wisconsin WIC Checks Accepted Here - Stickers DPH
F-10075 Wisconsin Well Woman Medicaid Application and Renewal DMS
F-40041 Certification and Food Package Pick-Up DPH
F-44727 WIC Vendor Training Proof DPH
F-04020L Student Immunization Record, Long DPH
F-10076 SeniorCare Application DMS
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-10112 Medicaid Disability Application DMS
F-16104 Local Agency Customer Feedback DMS
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application DMS
F-01320 Lead Test Kit Documentation DPH
F-00036 Power of Attorney for Finance and Property DPH
F-00060 Declaration to Physicians (Living Will) DPH
F-00086 Authorization for Final Disposition DPH
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election DMS
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation DQA
F-10112A Medicaid – Disability Application Addendum DMS
F-11271 Personal Care Provider Addendum DMS
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS
F-00685 Statement of Tribal Affiliation DMS
F-11022 Rural Health Clinic Statistical Data DMS


Last Revised: March 23, 2021