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-01145 Wisconsin Hemophilia Home Care Program Residency Verification DMS
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide DQA
F-01997 Children's Community Options (CCOP) Reconciliation Packet DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-00987 EMS Service Operational Plan, Advanced Skills Addendum (Basic) DPH
F-62316 Hospice Patient Rights DQA
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-11129A Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions DMS
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review DPH
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-02614 Fraud Prevention and Investigation Program (FPIP) Fraud Year Contact Information OIG
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-00633 Notice and Consent for Screening DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DMS
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change DMS
F-00315D Written Prior Notice - Additional Assessment Recommended DMS
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-01352 Background Check Appeal Request - IRIS Program DMS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate DMS
F-02377 Supported Decision-Making Agreement DPH
F-01205B IRIS Participant Education: Budget Amendments DMS
F-01407 Checklist (Asthma Care and Environmental Strategies) DPH
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs DQA
F-02702 Pre-Release Enrollment Agreement DPH
F-02046 IRIS Financial Projections Template DMS
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-40028 Participant Determination Letter DPH
F-16019B FoodShare Wisconsin Registration Packet DMS
F-82009AA Confidential Information Release Authorization - Katie Beckett Program DMS
F-44702 Vaccine Administration Record DPH
F-04020 Student Immunization Record - This form is intended for schools DPH
F-16019A FoodShare Wisconsin Registration DMS
F-04020L Student Immunization Record, Long DPH
F-10182 BadgerCare Plus Application Packet DMS
F-44089 Wisconsin WIC Checks Accepted Here - Stickers DPH
F-40041 Certification and Food Package Pick-Up DPH
F-10183 Information Change Report DMS
F-10075 Wisconsin Well Woman Medicaid Application and Renewal DMS
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-10112 Medicaid Disability Application DMS
F-16104 Local Agency Customer Feedback DMS

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Last Revised: March 23, 2021