Hospitals - Forms

For questions regarding general and critical access hospitals, you may contact us via email: Division of Quality Assurance.

For information concerning processing state and federal certifications for Wisconsin general and critical access hospitals, contact the Bureau of Health Services at 608-266-7485.

All fires in a licensed health or residential care facility in Wisconsin must be reported to the Department of Health Services within 72 hours (check specific rule requirements).

  • You may use the Fire Report, F-62500 (Word) and fax to 608-267-0352. Questions about this process may be directed to the "Fire Authority" at 608-266-8016. Refer to DQA memo 17-003 (PDF) for additional information.

State Mandated Report of Death by Suicide, Seclusion/Restraint or Psychotropic Drugs. 

CMS S&C Memo 14-27, Hospital Restraint/Seclusion Deaths to be Reported Using the Centers for Medicare and Medicaid Services (CMS) Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion.

Wisconsin Client Rights and Grievance Procedure.

Plan Review Requirements - Construction/Remodeling of Health Care Facilities.

Last Revised: April 4, 2017