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 Title Other Locationsort descending
F-11136 Personal Care Addendum
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program
F-01989 Renewal Application – Individual Lead Disciplines
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters
F-60309 Self-Supervision Evaluation and Waiver Request
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36
F-01161 Abortion Certification Statements
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist
F-01003 Wisconsin Medicaid Certification of Public Expenditures
F-01542 Notification of Required Drug Testing
F-00728 Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix
F-00054 Request for Waiver of Education / Experience Requirements (ADRC)
F-00989H Child/Family Outcome (IFSP)
F-00539A General Support and Service Coordination Rate Certification Worksheet
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility
F-25206 Petition for Capias
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request
F-16022 Social Security Number Referral
F-16014 Notice of Program Violation
F-00123 Wisconsin Declaration of Domestic Partnership Application
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-20933 Court Order for Assessment
F-00380 Outpatient Mental Health Clinic Certification Withdrawal
F-10162 Verification of Veterans Benefits
F-02257 Temperature Excursion Incident Report - Wisconsin Vaccines for Children Program (VFC)
F-00272 WisTech Assistive Technology Advisory Council Member Application
F-05260 Letter of Non-Marriage Application
F-80751 Non-County Resident Proceedings Cost Certification
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys
F-62610 Nurse Aide Training Program Primary Instructor Application
F-62274A Personal Care Agency Consent for Home Visit
F-47463C Intermediate Technician Operational Plan Components
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-01205D IRIS Participant Education: Program Integrity - Fraud Prevention
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-01068K General Pediatric Clinic - Elementary School Visit
F-01622 OARS Records Checklist
F-00926A Request for Use of Medical Restraints – CLTSS
F-45007 Certificate of Disposition of Materials
F-01579 Wisconsin eWIC Cash Register System Survey
F-44003 Lead-Safe Renovator Application
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program
F-40072 8 Week Activity Log
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure


Last Revised: May 22, 2018