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-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
F-11055 STAT-PA System Instructions DMS
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-02430 Statement About Immigration Status DMS
F-02431 Statement About U.S. Military Service DMS
F-10161 Statement of Citizenship and/or Identity DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-25177 Statement of Probable Cause and Detention and Petition for Revocation DCTS
F-00685 Statement of Tribal Affiliation DMS
F-20935 Status Report to Court for Plan Compliance DCTS
F-01344 Strategies for Success with People Who Have Dementia-Behavior Analysis Worksheet-Model DPH
F-16023 Striker Evaluation DMS
F-16031 Student Aid and Expense Worksheet DMS
F-16021 Student Financial Aid Report DMS
F-04020 Student Immunization Record - This form is intended for schools DPH
F-04020L Student Immunization Record, Long DPH
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-02643 Student Nurse Aide Skills Checklist DQA
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request DCTS
F-22567 Substance Abuse Prevention Treatment Block Grant Annual Reporting DCTS
F-00989B Summary of Development (IFSP) DMS
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) DMS
F-00989C Summary of Development Child’s Positive Social Emotional Skills (IFSP) DMS
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP) DMS
F-00098 Summary of Information Letter DMS
F-00989L Summary of Services (IFSP) DMS

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Last Revised: March 26, 2019