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-00568 EMS Board Sub-Committee Appointment Application DPH
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-02593 Rapid Testing Log DPH
F-10162 Verification of Veterans Benefits DMS
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-00401 Preferred Drug List Expedited Emergency Supply Request DMS
F-44016 Asbestos Occupant Protection Plan DPH
F-02107C Family Adult Day Care Center – New Provider Certification Application DQA
F-00989H Child/Family Outcome (IFSP) DMS
F-00263 Personal Care Agency Record Review DQA
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH
F-01309 IRIS Program Orientation and Enrollment Checklist DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-00098 Summary of Information Letter 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-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter DMS
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement DMS
F-02737 COVID Impact Survey for Behavioral Health Providers – Prep DCTS
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-01942B LTC FS - Request Letter DMS
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35 DQA
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-02610A Rental Property - Lead-Safe Homes Program Application DPH
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
F-01761 Intoxicated Driver Program Self-Evaluation DCTS
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-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS
F-16014 Notice of Program Violation DMS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-01020 Nursing Home Care Determination Request DMS
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS
F-12022 Managed Care Program Provider Appeal DMS
F-01942C LTC FS - Release of Information Authorization DMS
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS
F-60367 Community Advisory Committee Documentation DQA
F-02610B Occupant Worksheet - Lead-Safe Homes Program Application DPH
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter DMS
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 DQA
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH
F-10137 Medicaid Change Report DMS
F-44192 Child Care Immunization Record DPH
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-02483 PACE Program Enrollment DPH
F-00726 Typical Vision Developmental Milestones DMS

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Last Revised: March 23, 2021