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 ascending Division Other Location
F-10076 SeniorCare Application DMS
F-01999B Senior Companion Program: State Match Funding Application DPH
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-00107 Self-Employment Income Report DMS
F-44212 School Report to the District Attorney DPH
F-04002 School Report to Local Health Department DPH
F-45029 School Food Safety Program Inspection Report DPH
F-11022 Rural Health Clinic Statistical Data DMS
F-11027 Rural Health Clinic Quarterly Cost Report DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-01558 Risk Agreement – IRIS Program DMS
F-62601 Rights of Home Health Agency Patients DQA
F-21189 Rights of Detention DCTS
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-02634C Residential Care Apartment Complex (RCAC) Initial Survey Checklist DQA
F-02282 Resident Relocation Roster DMS
F-02282A Resident Relocation Plan DMS
F-62373 Resident Evacuation Assessment DQA
F-69260 Resident Census and Conditions of Residents CMS-672 DQA
F-00923 Reschedule Lead (PB) Certification Exam DPH
F-01885 Requesting State Trauma Registry Access DPH
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F02637 Requesting FSIA Access During COVID-19 Health Emergency DMS
F-05029 Request To Withdraw Voluntary Paternity Acknowledgement DPH
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center DPH
F-19002 Request to Reduce QUEST Card Balance DMS
F-02068 Request to Establish a Children's COP Risk Reserve DMS
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate DMS
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS
F-00054 Request for Waiver of Education / Experience Requirements (ADRC) DPH
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTS DMS
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS
F-00926A Request for Use of Medical Restraints – CLTS DMS
F-62608 Request for Use of Medical Restraints DMS
F-20572 Request for State Public Funding for Non-Residents DCTS
F-00330 Request for Replacement FoodShare Benefits DMS
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS

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Last Revised: March 26, 2019