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 Numbersort ascending Title Division Other Location
F-42029 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) and/or Varicella Vaccine DPH
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment DPH
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program DPH
F-42024 Vaccine Fahrenheit Temperature Log DPH
F-42023 Vaccine Celsius Temperature Log DPH
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results DPH
F-42017 Wisconsin Initial Refugee Health Assessment DPH
F-42016 Authorization for Release of Confidential HIV Test Results DPH
F-42014 Acuity Index DPH
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up DPH
F-42010 Interjurisdictional Tuberculosis Notification DPH
F-42007 Mail Label 3 X 4 - Immunization Program DPH
F-42002 Warning: Do Not Unplug Refrigerator - Label DPH
F-42001 Tuberculosis Suspect Case Data DPH
F-42000 Vaccine Order DPH
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services DPH
F-40310 Adult Oral Health Screening (PDF, 176 KB) DPH
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB) DPH
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB) DPH
F-40303 Early Childhood Caries Prevention Screening DPH
F-40117 Abortion Information Provision Certification DPH
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-40104 WIC Retail Vendor Annual Food Sales Survey DPH
F-40098 Worksite Wellness Kit Survey and Request DPH
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement DPH
F-40096 eWIC Program Repayment Agreement DPH
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-40092 Physical Activity Zone DPH
F-40085 WIC Program Notice of Ineligibility DPH
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-40075 Pedometer Walking Program DPH
F-40074 Annual Physical Activity Record DPH
F-40073 Monthly Physical Activity Sheet DPH
F-40072 8 Week Activity Log DPH
F-40071 Children's Physical Activity Chart DPH
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-40060 The Emergency Food Assistance Program Commodities Inventory Report DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-40058 Verification of Transfer of USDA Commodities DPH
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program DPH
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers DPH
F-40054 Confidential Birth Defects Registry Report DPH
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training DPH
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-40041 Certification and Food Package Pick-Up DPH
F-40040 Envelope - Vendor and Integrity Unit #9 DPH

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Last Revised: March 26, 2019