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-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-02605 Home and Community-Based Services (HCBS) Settings Rule DMS
F-00942 Meet Our "Henry" DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-00588a PPS AODA Deskcard DCTS
F-01621 Smoking Cessation Data Collection DCTS
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-02106B Adult Day Care Center – Established Provider Certification Application Checklist DQA
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 DQA
F-00989M Justification for Services Provided in Locations Other than Natural Environments (IFSP) DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-00309 Medicaid Provider Report DQA
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-01418 21-Day Monitoring Period Chart DPH
F-01332 Predispositional Investigation Report (PDI) DCTS
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-21343E Alzheimer's Family and Caregiver Support Program (AFCSP) General Information DPH
F-02828 School P-EBT Verification Letter Template DMS
F-82009 Confidential Information Release Authorization - Generic  DES
F-11136 Personal Care Addendum DMS
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS
F-16025 Disqualification Consent Agreement DMS
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation DQA
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-82009F Confidential Information Release Authorization: WISHIN DCTS
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process DMS
F-62024 Report of Hours Worked - Nurse Aide / Day DQA
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) DPH
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 DQA
F-45010D Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) DPH
F-01601B ISP Line Item Detail Budget DCTS
F-10147 Wisconsin Veterans Home at King - Medicaid Review DMS
F-02288 WisCaregiver Career Program: Registration Agreement DQA
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-43026 Wisconsin Donor Registry User Access Request DPH
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-25393 Petition for Conditional Release DCTS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
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-01261 Fraud Statement - IRIS Program DMS
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement DPH
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-02778 Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply CRT
F-01164 Consent for Sterilization DMS
F-62688 Feeding Assistant Training Program Trainer Application DQA

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Last Revised: March 23, 2021