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-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-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-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-83292 Small Business Concern Feedback OS
F-01621 Smoking Cessation Data Collection DCTS
F-16022 Social Security Number Referral DMS
F-01345 Special Care Environment Working Document DPH
F-80857 Special CARS Run request DES
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


Last Revised: March 26, 2019