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-62645A Drug Repository Program: Transfer Record DQA
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-62025 Report of Hours Worked - Registered Nurse / Evening DQA
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-01788 Certification Regarding Debarment and Suspension DES
F-00546 Community Support Program (CSP) for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 DQA
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-01618 Medicare Counseling Client Services Agreement DPH
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-62645B Drug Repository Program: Donation Record DQA
F-62026 Report of Hours Worked - Nurse Aide / Evening DQA
F-11042 Prior Authorization Amendment Request DMS
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse DQA
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) DPH
F-10150A Your Rights and Responsibilities for Health Care DMS
F-01631 ADRC Call Summary Sheet DPH
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist DQA
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-00634B Records Access Log, Birth to 3 Program DMS
F-25614 Conditional Release Rules and Conditions DCTS
F-82009V Confidential Information Release Authorization: Rehabilitation Review OLC
F-01204E Letter – IRIS Program Notice of Action – Functional Eligibility DMS
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement DPH
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility DCTS
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications DQA
F-02716 Authorization to Allocate Elder Benefit Specialist Funding to the Aging and Disability Resource Center DPH
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report DQA
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis DMS
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses DMS
F-02538A CLTS Provider Cost-Based Outlier DMS
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 DQA

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Last Revised: March 23, 2021