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Forms: Numeric List 
F-00001 Through F-09999

This numeric list contains forms that are available from this site.  A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms.   Microsoft Word - Fillable or Excel forms, can be filled in, saved, and transmitted electronically.  You must have access to Microsoft Office 97, or a more recent version, to use these forms.
Division Prefix / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
DLTC F-00004 Health and Employment Counseling Application word None English
DPH F-00005 Senior FMNP Agency Application to Participate word None English
DHCAA F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request pdf None English
DLTC F-00010 Risk Agreement - Participant word None English
DQA F-00012 CBRF Completion Documents PDF None English
DQA F-00014 Ceiling Closure Inspection Checklist PDF None English
DQA F-00014 Ceiling Closure Inspection Checklist Word None English
DQA F-00015 Final Occupancy Inspection Checklist PDF None English
DQA F-00015 Final Occupancy Inspection Checklist Word None English
DQA F-00016 Wall Closure Inspection Checklist PDF None English
DQA F-00016 Wall Closure Inspection Checklist Word None English
DPH F-00017 Blood Lead Lab Reporting pdf None English
DPH F-00017 Blood Lead Lab Reporting word None English
DHCAA F-00020 ForwardHealth Drug Addition Review Request pdf None English
DHCAA F-00021 ForwardHealth HealthCheck Referral pdf None English
DLTC F-00022 ForwardHealth Nursing Home Rate Administrative Review Request pdf None English
DLTC F-00022A ForwardHealth Nursing Home Rate Administrative Review Request Completion Instructions PDF None English
DHCAA F-00023 ForwardHealth Case Management Agency Self-Audit Checklist pdf None English
DES F-00024 HSRS CORE Summary Report Excel None English
DMHSAS F-00029 Substance Abuse Teleconference Evaluation System None English
DHCAA F-00030 ForwardHealth Drug Pricing Review Request pdf None English
DPH-00036 F-00036 Statutory Power of Attorney PDF Advance Directives English
DLTC/DMHSAS F-00037 Sign-Up Functional Screen Listserv HTML None English
DLTC F-00037B Sign-Up Expanding Managed Long Term Care in Wisconsin Listserv HTML None English
DQA F-00037D Sign-Up DQA E-Mail Subscription Service HTML None English
DPH F-00039 Asbestos Course Accreditation - Initial PDF None English
DPH F-00040 Asbestos Course Accreditation - Renewal PDF None English
DPH F-00041 Asbestos Project Notification PDF None English
DPH F-00041 Asbestos Project Notification word None English
DLTC F-00043 Communication to Local Educational Agency Regarding Child Referral word None English
DLTC F-00044 User Agreement for Access to Program Participation System word None English
DLTC F-00046 Family Care, PACE and Partnership Programs Enrollment, Instructions and Important Information word None English
DPH F-00047 Designated Asbestos Coordinator PDF None English
DPH F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) PDF None English
DPH F-00048H Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) - Hmong PDF None Hmong
DPH F-00048S Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) - Spanish PDF None Spanish
DPH F-00049 Asbestos Principal Instructor PDF None English
DLTC F-00050 Oral Health Preliminary Exam and Prevention Services PDF None English
DPH F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) PDF None English
DPH F-00051H Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) - Hmong PDF None Hmong
DPH F-00051S Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) - Spanish PDF None Spanish
DLTC F-00052 Aging and Disability Resource Center (ADRC) Application Word None English
DLTC F-00052A Aging and Disability Resource Center (ADRC) Annual Budget Excel None English
DLTC F-00053 Notice of Intent to Submit an Application (ADRC) word None English
DLTC F-00054 Request for Waiver of Education / Experience Requirements (ADRC) word None English
DPH-00060 F-00060 Declaration To Physicians PDF Advance Directives English
DPH-00060A F-00060A Declaration To Physicians - Letter PDF Advance Directives English
DPH F-00064 Antiviral Treatment Reporting PDF None English
DHCAA F-00065 Roster Billing Form for Reimbursement for Treatment and Vaccination of the Uninsured Excel None English
DHCAA F-00065A Roster Billing Form Completion Instructions Reimbursement for Treatment and Vaccination of the Uninsured PDF None English
DLTC F-00075 IRIS (Include, Respect, I Self-Direct) Referral / Authorization word None English
DLTC F-00076 Variance Request - Wait List PDF None English
DLTC F-00076 Variance Request - Wait List word None English
DCHAA F-00079 ForwardHealth Prior Authorization Drug Attachment for Provigil pdf None English
DCHAA F-00079 ForwardHealth Prior Authorization Drug Attachment for Provigil word None English
DCHAA F-00079A ForwardHealth Prior Authorization Drug Attachment for Provigil Completion Instructions PDF None English
DCHAA F-00080 ForwardHealth Prior Authorization Drug Attachment for Byetta and Symlin pdf None English
DCHAA F-00080 ForwardHealth Prior Authorization Drug Attachment for Byetta and Symlin word None English
DCHAA F-00080A ForwardHealth Prior Authorization Drug Attachment for Byetta and Symlin Completion Instructions PDF None English
DCHAA F-00081 ForwardHealth Prior Authorization Drug Attachment for Suboxone and Subutex pdf None English
DCHAA F-00081 ForwardHealth Prior Authorization Drug Attachment for Suboxone and Subutex word None English
DCHAA F-00081A ForwardHealth Prior Authorization Drug Attachment for Suboxone and Subutex Completion Instructions PDF None English
DPH-00085 F-00085 Power of Attorney for Health Care PDF Advance Directives English
DPH-00085A F-00085A Power of Attorney for Health Care - Letter PDF Advance Directives English
DPH-00086 F-00086 Authorization for Final Disposition PDF None English
DHCAA F-00098 Summary of Information Form Letter word None English
DHCAA F-00100 State Vital Records Cover Letter word None English
DHCAA F-00100E Enrollment Services Center State Vital Records Letter word None English
DHCAA F-00101 Authorization to Request Birth Records word None English
DLTC F-00102 Children's Long-Term Support Waivers HSRS Slot Change Request PDF None English
DLTC F-00102 Children's Long-Term Support Waivers HSRS Slot Change Request word None English
DHCAA F-00107 Self-Employment Income Report pdf None English
DHCAA F-00107H Self-Employment Income Report - Hmong pdf None Hmong
DHCAA F-00107S Self-Employment Income Report - Spanish pdf None Spanish
DLTC F-00113 Four Conditions for the Use of Funding in a CBRF word None English
DMHSAS F-00115 Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument Word None English
DPH F-00123 Wisconsin Declaration of Domestic Partnership Application pdf none English
DPH F-00124 Wisconsin Termination Domestic Partnership Certificate Application pdf none English
DPH F-00126 Fax Application Declaration Wisconsin Domestic Partnership pdf none English
DPH F-00127 Fax Application Declaration Wisconsin Domestic Partnership pdf none English
DHCAA F-00136 FoodShare Employment and Training (FSET) Participation Agreement PDF None English
DHCAA F-00136H FoodShare Employment and Training (FSET) Participation Agreement - Hmong pdf None Hmong
DHCAA F-00136S FoodShare Employment and Training (FSET) Participation Agreement - Spanish pdf None Spanish
DHCAA F-00142 ForwardHealth Prior Authorization Drug Attachment for Synagis pdf None English
DHCAA F-00142 ForwardHealth Prior Authorization Drug Attachment for Synagis word None English
DHCAA F-00142A ForwardHealth Prior Authorization Drug Attachment for Synagis Completion Instructions pdf None English
DLTC F-00152 MCO Request to Pay Over the Medicaid Fee-for-Service Reimbursement Rate Word None English
DLTC F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request Excel None English
DMHSAS F-00153 Commitment to Offer Community Recovery Services (CRS) Word None English
DHCAA F-00154 Wisconsin Consultative Examination Inquiry pdf None English
DQA F-00161 Caregiver Misconduct Reporting Requirements Worksheet PDF None English
DQA F-00161 Caregiver Misconduct Reporting Requirements Worksheet Word None English
DQA F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries PDF None English
DHCAA F-00162 ForwardHealth Prior Authorization Drug Attachment for Lovaza PDF None English
DHCAA F-00162 ForwardHealth Prior Authorization Drug Attachment for Lovaza Word None English
DHCAA F-00162I ForwardHealth Prior Authorization Drug Attachment for Lovaza Completion Instructions PDF None English
DHCAA F-00163 ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs PDF None English
DHCAA F-00163 ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Word None English
DHCAA F-00163I ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Completion Instructions PDF None English
DPH F-00168 (Novel) 2009 Influenza A (H1N1) Virus Hospitalizaitons or Deaths Case Report PDF None English
DLTC F-00169 Opting Out of LEA Notification PDF None English
DPH F-00171 Lead-Based Paint Activities & Investigations Certification Application - Company PDF None English
DLTC F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies word None English
DLTC F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers word None English
DLTC F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports word None English
HCF-01002 F-01002 HealthCheck Individual Health History PDF None English
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong PDF None Hmong
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish PDF None Spanish
HCF-01003 F-01003 Certification of Public Expenditures pdf None English
HCF-01004 F-01004 Wisconsin Medicaid School-Based Services Matching Expenditures pdf None English
HCF-01004A F-01004A Wisconsin Medicaid School-Based Services Matching Expenditures Completion Instructions PDF None English
HCF-01008 F-01008 Wisconsin Medicaid Notification of Medicaid Hospice Benefit Election pdf None English
HCF-01008 F-01008 Wisconsin Medicaid Notification of Medicaid Hospice Benefit Election word None English
HCF-01009 F-01009 Wisconsin Medicaid Member Election of Hospice Benefit pdf None English
HCF-01009 F-01009 Wisconsin Medicaid Member Election of Hospice Benefit word None English
HCF-01010 F-01010 Wisconsin Medicaid Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge pdf None English
HCF-01010 F-01010 Wisconsin Medicaid Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge word None English
HCF-01011 F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness pdf None English
HCF-01011 F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness word None English
HCF-01012 F-01012 ForwardHealth Reimbursement Request for a PASARR Level I Screen pdf None English
HCF-01012 F-01012 ForwardHealth Reimbursement Request for a PASARR Level I Screen word None English
HCF-01012A F-01012A ForwardHealth Reimbursement Request for a PASARR Level I Screen Instructions PDF None English
HCF-01013 F-01013 ForwardHealth Nurses Aide Training and Competency Test Reimbursement Request pdf None English
HCF-01013 F-01013 ForwardHealth Nurse Aide Training and Competency Test Reimbursement Request word None English
HCF-01013A F-01013A ForwardHealth Nurses Aide Training and Competency Test Reimbursement Request Instructions PDF None English
HCF-01016 F-01016 ForwardHealth Provider Suggestion pdf None English
HCF-01017 F-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement pdf None English
HCF-01017 F-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement word None English
HCF-01017A F-01017A Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Completion Instructions PDF None English
HCF-01018 F-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers pdf None English
HCF-01018 F-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers word None English
HCF-01020 F-01020 Wisconsin Medicaid Request for Nursing Home Care Determination pdf None English
HCF-01020 F-01020 Wisconsin Medicaid Request for Nursing Home Care Determination word None English
HCF-01020A F-01020A Wisconsin Medicaid Request for Nursing Home Care Determination Completion Instructions PDF None English
HCF-01021 F-01021 Relief Block Grant Claim Paper Forms Manager English
HCF-01021A F-01021A Relief Block Grant Claim Instructions (Form Letter) Paper Forms Manager English
HCF-01022A-E F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease Excel None English
HCF-01050 F-01050 Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification PDF None English
HCF-01050A F-01050A Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions PDF None English
HCF-01058 F-01058 Wisconsin Chronic Renal Disease Program Drug Benefits Important Notice PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review PDF None English
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish PDF None Spanish
HCF-01063 F-01063 HealthCheck Family History PDF None English
HCF-01063S F-01063S HealthCheck Family History PDF None Spanish
HCF-01066 F-01066 HealthCheck Infant's Food Record / Birth to 12 Months of Age PDF None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Agef Age PDF None English
HCF-01066AS F-01066AS HealthCheck Child's Food Record (1 to 12 Years of Age) - Spanish PDF None Spanish
HCF-01066B F-01066B HealthCheck Adolescent's Food Record / 13 to 20 Years of Age PDF None English
HCF-01066BS F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age) - Spanish PDF None Spanish
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing PDF None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit PDF None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit PDF None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit PDF None English
HCF-01068D F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit PDF None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit PDF None English
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit PDF None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit PDF None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit PDF None English
HCF-01068I F-01068I HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit PDF None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit PDF None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit PDF None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit PDF None English
HCF-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey PDF None English
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish PDF None Spanish
DHCAA F-01069 Ambulance Certification Criteria System Provider Services English
DHCAA F-01070 Ambulance Terms of Reimbursement System Provider Services English
DHCAA F-01071 Ambulatory Surgical Center Certification Criteria System Provider Services English
DHCAA F-01072 Ambulatory Surgical Center Terms of Reimbursement System Provider Services English
DHCAA F-01073 Anesthetist Certification Criteria System Provider Services English
DHCAA F-01074 Anesthetist Terms of Reimbursement System Provider Services English
DHCAA F-01077 Audiologist Certification Criteria System Provider Services English
DHCAA F-01078 Hearing Instrument Specialist (Hearing Aid Dealer) Certification Criteria System Provider Services English
DHCAA F-01079 Speech and Hearing Clinic Certification Criteria System Provider Services English
DHCAA F-01080 Speech-Language Pathologist Certification Criteria System Provider Services English
DHCAA F-01081 Speech-Language Pathology Non-Billing Performing Providers Certification Criteria System Provider Services English
DHCAA F-01082 Audiology Terms of Reimbursement System Provider Services English
DHCAA F-01083 Hearing Instrument Specialist Terms of Reimbursement System Provider Services English
DHCAA F-01084 Speech - Language Pathology Therapy Terms of Reimbursement System Provider Services English
DHCAA F-01085 Case Management Certification Criteria System Provider Services English
DHCAA F-01087 Chiropractor Certification Criteria System Provider Services English
DHCAA F-01088 Chiropractor Terms of Reimbursement System Provider Services English
DHCAA F-01089 Dental Certification Criteria System Provider Services English
DHCAA F-01090 Clinic Certification Criteria System Provider Services English
DHCAA F-01091 Dental Hygienist Certification Criteria System Provider Services English
DHCAA F-01092 Dental - Dental Hygienists Terms of Reimbursement System Provider Services English
DHCAA F-01093 Dialysis Faculty (End-Stage Renal Disease) Certification Criteria System Provider Services English
DHCAA F-01094 Free Standing End-Stage Renal Disease Provider Terms of Reimbursement System Provider Services English
DHCAA F-01095 Hospital Affiliated End-Stage Renal Disease Provider Terms of Reimbursement System Provider Services English
DHCAA F-01099 Family Planning Clinic Terms of Reimbursement System Provider Services English
DHCAA F-01101 Federally Qualified Health Center Certification Criteria System Provider Services English
HCF-01105 F-01105 ForwardHealth PreNatal Care Coordination Pregnancy Questionnaire pdf Forms Center English
HCF-01105A F-01105A ForwardHealth PreNatal Care Coordination Pregnancy Questionnaire Completion Instructions PDF None English
HCF-01105H F-01105H ForwardHealth PreNatal Care Coordination Pregnancy Questionnaire - Hmong PDF None Hmong
HCF-01105S F-01105S Wisconsin Medicaid Pre-Natal Care Coordination Program Pregnancy Questionnaire - Spanish PDF None Spanish
DHCAA F-01108 Federally Qulified Health Center Terms of Reimbursement Criteria System Provider Services English
HCF-01111A F-01111A Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation System None English
HCF-01112 F-01112 HealthCheck Verification Card Paper Forms Center English
DHCAA F-01113 HealthCheck Other Services Provider Terms of Reimbursement System Provider Services English
DHCAA F-01114 HealthCheck Screener and Case Management Provider Terms of Reimbursement System Provider Services English
DHCAA F-01116 HealthCheck Program Overview System Provider Services English
DHCAA F-01117 Wisconsin Medicaid HealthCheck System Provider Services English
HCF-01118 F-01118 ForwardHealth Child Care Coordination Family Questionnaire pdf Forms Center English
DHCAA F-01118A ForwardHealth Child Care Coordination Family Questionnaire Completion Instructions PDF None English
DHCAA F-01119 Wisconsin Medicaid Outreach and Case Management Policies System Provider Services English
DHCAA F-01120 Home Health Agency Certification Criteria System Provider Services English
DHCAA F-01121 Home Health Agency Terms of Reimbursement System Provider Services English
DHCAA F-01124 Hospice Certification Criteria System Provider Services English
DHCAA F-01125 Hospice Terms of Reimbursement System Provider Services English
DHCAA F-01126 Wisconsin Medicaid Hospice Certification Criteria System Provider Services English
DHCAA F-01127 Border Status Hospitals Terms of Reimbursement System Provider Services English
DHCAA F-01128 Hospital Terms of Reimbursement System Provider Services English
DHCAA F-01129 Laboratory Certification Criteria System Provider Services English
DHCAA F-01130 Laboratories Terms of Reimbursement System Provider Services English
DHCAA F-01131 Blood Banks Terms of Reimbursement System Provider Services English
DHCAA F-01132 Independent Nurse Certification Criteria System Provider Services English
DHCAA F-01133 Wisconsin Medicaid 24 Hour Drug FAX Cover Sheet Paper Provider Services English
HCF-01134 F-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit pdf None English
HCF-01134 F-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit word None English
HCF-01142 F-01142 ForwardHealth Request for Discretionary Waiver of Qualifications For a Registered Nurse Supervisor pdf None English
HCF-01143 F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification PDF None English
HCF-01144 F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification PDF None English
HCF-01145 F-01145 Wisconsin Hemophilia Home Care Program Residency Verification PDF None English
HCF-01146 F-01146 Wisconsin Chronic Disease Program Provider Data Sheet PDF None English
HCF-01147 F-01147 Notice of Intent - Chapter 150 Program, Long Term Care / Resource Allocation Program word None English
HCF-01148 F-01148 Chapter 150 Program, Application for Renewing the Approval of a Distinct Part Facility for the Developmentally Disabled (FDD) word None English
HCF-01149 F-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements pdf None English
HCF-01149 F-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements word None English
HCF-01151 F-01151 ForwardHealth Personal Care Worker Weekly Record of Care Optional (Single Member with or More Funding Sources) pdf None English
HCF-01151A F-01151A ForwardHealth Personal Care Worker Weekly Record of Care Optional (Single Member with or More Funding Sources) Completion InstructionsMedicaid Personal Care Worker Weekly Record of Care (single recipient with one or more funding sources) Instructions PDF None English
HCF-01152 F-01152 ForwardHealth Personal Care Worker Daily Record of Care Optional (Two or More Personal Care Workers for One Member in a Group Living Situation) pdf None English
HCF-01152A F-01152A ForwardHealth Personal Care Worker Daily Record of Care Optional (Two or More Personal Care Workers for One Member in a Group Living Situation) Completion Instructions PDF None English
HCF-01153 F-01153 ForwardHealth Breast Pump Order pdf None English
HCF-01159 F-01159 Wisconsin Medicaid Other Coverage Discrepancy Report pdf None English
HCF-01159 F-01159 Wisconsin Medicaid Other Coverage Discrepancy Report word None English
HCF-01160 F-01160 ForwardHealth Acknowledgement of Receipt of Hysterectomy Information pdf None English
HCF-01160 F-01160 ForwardHealth Acknowledgement of Receipt of Hysterectomy Information word None English
HCF-01161 F-01161 ForwardHealth Abortion Certification Statements pdf None English
HCF-01161 F-01161 ForwardHealth Abortion Certification Statements word None English
HCF-01162 F-01162 ForwardHealth Certification of Emergency for Non-U.S. Citizens pdf None English
HCF-01162A F-01162A ForwardHealth Certification of Emergency for Non-U.S. Citizens PDF None English
HCF-01164 F-01164 ForwardHealth Consent for Sterilization pdf None English
HCF-01164 F-01164 ForwardHealth Consent for Sterilization word None English
HCF-01164A F-01164A ForwardHealth Consent for Sterilization Instructions PDF None English
HCF-01164S F-01164S ForwardHealth Consent for Sterilization - Spanish pdf None Spanish
HCF-01165 F-01165 Wisconsin Medicaid Newborn Report pdf None English
HCF-01165 F-01165 Wisconsin Medicaid Newborn Report word None English
HCF-01168 F-01168 ForwardHealth Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases pdf None English
HCF-01168 F-01168 ForwardHealth Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases word None English
HCF-01170 F-01170 Wisconsin Medicaid Written Correspondence Inquiry pdf None English
HCF-01170 F-01170 Wisconsin Medicaid Written Correspondence Inquiry word None English
HCF-01174 F-01174 ForwardHealth Medical Professional Statement in Support of Request for Variance of 60-Day Supervisory Visit Requirement pdf None English
HCF-01174 F-01174 ForwardHealth Medical Professional Statement in Support of Request for Variance of 60-Day Supervisory Visit Requirement word None English
HCF-01175 F-01175 ForwardHealth Member Request for Variance of 60=Day Supervisory Visit Requirement pdf None English
HCF-01175 F-01175 ForwardHealth Member Request for Variance of 60=Day Supervisory Visit Requirement word None English
HCF-01176 F-01176 ForwardHealth Prior Authorization Fax Cover Sheet pdf None English
HCF-01176 F-01176 ForwardHealth Prior Authorization Fax Cover Sheet word None English
HCF-01181 F-01181 Wisconsin Medicaid Provider Change of Address or Status pdf None English
HCF-01181 F-01181 Wisconsin Medicaid Provider Change of Address or Status word None English
HCF-01181A F-01181A Wisconsin Medicaid Provider Change of Address or Status Instructions PDF None English
HCF-01182 F-01182 ForwardHealth Declaration of Supervision for Nonbilling Providers pdf None English
HCF-01182 F-01182 ForwardHealth Declaration of Supervision for Nonbilling Providers word None English
HCF-01184 F-01184 Wisconsin Hemophilia Home Care Program Application PDF None English
HCF-01184A F-01184A Wisconsin Hemophilia Home Care Program Application Instructions PDF None English
HCF-01185 F-01185 Wisconsin Adult Cystic Fibrosis Program Application PDF None English
HCF-01185A F-01185A Wisconsin Adult Cystic Fibrosis Program Application Instructions PDF None English
HCF-01186 F-01186 Wisconsin Chronic Renal Disease Program Application PDF None English
HCF-01186A F-01186A Wisconsin Chronic Renal Disease Program Application Instructions PDF None English
HCF-01187 F-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement PDF None English
HCF-01187A F-01187A Wisconsin Hemophilia Home Care Program Financial Need Statement Instructions PDF None English
HCF-01188 F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement PDF None English
HCF-01188A F-01188A Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Instructions PDF None English
HCF-01189 F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement PDF None English
HCF-01189A F-01189A Wisconsin Chronic Renal Disease Program Financial Need Statement Instructions PDF None English
HCF-01194 F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo PDF None English
HCF-01195 F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo PDF None English
HCF-01196 F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo PDF None English
HCF-01197 F-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation pdf None English
HCF-01197 F-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation word None English
HCF-01197A F-01197A Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation Completion Instructions PDF None English
HCF-01198 F-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services PDF None English
HCF-01198 F-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services word None English
HCF-01199 F-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration PDF None English
HCF-01199 F-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration word None English
HCF-01300 F-01300 Wisconsin Medicaid Specialized Medical Vehicle Information Chart pdf None English
HCF-01300 F-01300 Wisconsin Medicaid Specialized Medical Vehicle Information Chart word None English
HCF-01301 F-01301 Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart pdf None English
HCF-01301 F-01301 Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart word None English
HCF-01302 F-01302 Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report pdf None English
HCF-01302A F-01302A Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report instructions PDF None English
DHCAA F-01501 Private Duty Nursing to Ventilator-Dependent Members Terms of Reimbursement System Provider Services English
DHCAA F-01502 Private Duty Nursing Terms of Reimbursement System Provider Services English
DHCAA F-01504 Nurse Midwife Terms of Reimbursement System Provider Services English
DHCAA F-01505 Durable Medical Equipment and Medical Supplies Certification Criteria System Provider Services English
DHCAA F-01506 Medical Supply and Equipment Vendor Terms of Reimbursement System Provider Services English
DHCAA F-01507 Mental Health / Substance Abuse Services Terms of Reimbursement System Provider Services English
DHCAA F-01508 Nurse Practitioner Certification Criteria System Provider Services English
DHCAA F-01509 Nurse Practitioner Terms of Reimbursement System Provider Services English
DHCAA F-01511 Occupational Therapist and Assistant Certification Criteria System Provider Services English
DHCAA F-01512 Occupational Therapy Terms of Reimbursement System Provider Services English
DHCAA F-01513 Optician / Optometrist's Certification Criteria System Provider Services English
DHCAA F-01514 Optometrist / Optician Terms of Reimbursement System Provider Services English
DHCAA F-01515 Personal Care Provider Certification Criteria System Provider Services English
DHCAA F-01516 Personal Care Terms of Reimbursement System Provider Services English
DHCAA F-01517 Pharmacy Certification Criteria System Provider Services English
DHCAA F-01518 Pharmacy Terms of Reimbursement System Provider Services English
DHCAA F-01519 Physical Therapy and Assistants Certification Criteria System Provider Services English
DHCAA F-01520 Physical Therapy Terms of Reimbursement System Provider Services English
DHCAA F-01521 Physician Certification Criteria System Provider Services English
DHCAA F-01522 Physician Assistant Certification Criteria System Provider Services English
DHCAA F-01523 Physician and Physician Assistant Terms of Reimbursement System Provider Services English
DHCAA F-01524 Podiatrist Certification Criteria System Provider Services English
DHCAA F-01525 Podiatrist Terms of Reimbursement System Provider Services English
DHCAA F-01526 Portable X-Ray Provider Certification Criteria System Provider Services English
DHCAA F-01527 Portable X-Ray Terms of Reimbursement System Provider Services English
DHCAA F-01528 PreNatal Care Coordination Certification Criteria System Provider Services English
DHCAA F-01529 PreNatal Care Coordination Agency Terms of Reimbursement System Provider Services English
DHCAA F-01530 Rehabilitation Agency Certification Criteria System Provider Services English
DHCAA F-01531 Rehabilitation Agency Terms of Reimbursement System Provider Services English
DHCAA F-01532 Rural Health Clinic Certification Criteria System Provider Services English
DHCAA F-01533 Rural Health Clinic Terms of Reimbursement System Provider Services English
DHCAA F-01534 School-Based Services Certification Criteria System Provider Services English
DHCAA F-01535 School-Based Services Terms of Reimbursement System Provider Services English
DHCAA F-01536 Specialized Medical Vehicle Transportation Services Certification System Provider Services English
DHCAA F-01537 Specialized Medical Vehicle Terms of Reimbursement System Provider Services English
HCF-01538 F-01538 Wisconsin Medicaid School-Based Services Cost Report Excel None English
HCF-01538A F-01538A Wisconsin Medicaid School-Based Services Cost Report - Completion Instructions PDF None English
HCF-01538CW F-01538CW Wisconsin Medicaid School-Based Services Cost Report Compensation Data Worksheet Excel None English
HCF-01538WS F-01538WS Wisconsin Medicaid School-Based Services Cost Report Worksheet Excel None English
DHCAA F-01540 Wisconsin Chronic Disease Program Provider Application and Instructions System Provider Services English
DHCAA F-01541 Wisconsin Chronic Disease Program Provider Agreement and Acknowledgement of Terms of Participation (Standard for Individual and Clinic / Group / Agency Providers) System Provider Services English
HCF-01812 F-01812 Wisconsin Medicaid Program Nursing Home Cost Report PDF None English
HCF-01812A F-01812A Wisconsin Medicaid Program Nursing Home Cost Report Instructions PDF None English
HCF-01813 F-01813 Patients by Payer Source on Last Day of Quarter Excel None English
DPH-04002 F-04002 School Report to Local Health Department PDF Immunization Program English
DPH-04002 F-04002 School Report to Local Health Department Word Forms Center English
DPH-04020 F-04020 Student Immunization Record Paper Forms Center English
DPH-04020L F-04020L Student Immunization Record PDF Forms Center English
DPH-04020LH F-04020LH Student Immunization Record - Hmong PDF Forms Center Hmong
DPH-04020LS F-04020LS Student Immunization Record - Spanish PDF Forms Center Spanish
DPH-04020S F-04020S Student Immunization Record - Spanish Paper Forms Center Spanish
DPH-04021 F-04021 Age Grade Level Requirements Paper Immunization Program English
DPH-04021S F-04021S Age Grade Level Requirements - Spanish Paper Immunization Program Spanish
DPH-05004 F-05004 Birth Amendment - Affidavit Paper Vital Records English
DPH-05020 F-05020 Paternity Order Due to Divorce - Judgement Paper Vital Records English
DPH-05020A F-05020A Paternity Order Due to Divorce - Custody Paper Vital Records English
DPH-05021 F-05021 Report of Legal Name Change Paper None English
DPH-05021T F-05021T Report of Legal Name Change - Tribal Paper None English
DPH-05022 F-05022 Report of Adoption Paper Vital Records English
DPH-05022F F-05022F Report of Adoption - Child Born In A Foreign Country Paper Vital Records English
DPH-05022T F-05022T Report of Adoption - Tribal Paper Vital Records English
DPH-05023 F-05023 Acknowledgement of Marital Child Paper Forms Center English
DPH-05024 F-05024 Voluntary Paternity Acknowledgement Paper Vital Records English
DPH-05024S F-05024IS Reconocimento Voluntario de la Paternidad en Wisconsin - Instrucciones en Español Paper Vital Records Spanish
DPH-05027A F-05027A Report of Citizenship Paper Vital Records English
DPH-05027B F-05027B Report of Naturalization Paper Vital Records English
DPH-05029 F-05029 Request To Withdraw Voluntary Paternity Acknowledgement PDF Vital Records English
DPH-05032 F-05032 Report of Birth Certificate Changes After Surrogate Birth PDF Vital Records English
DPH-05033 F-05033 Birth Amendment - Baptismal Paper Vital Records English
DPH-05034 F-05034 Birth Certificate Facts Paper Vital Records English
DPH-05035 F-05035 Report Change Name, Sex Birth Certificate Surgical Procedure Word Vital Records English
DPH-05043 F-05043 Notice of Removal - Corpse (Hospital, Nursing Home, Hospice) Paper Vital Records English
DPH-05044 F-05044 Cause of Death Amendment Paper Vital Records English
DPH-05044C F-05044C Corner/Medical Examiner - Cause of Death Amendment Word Vital Records English
DPH-05045 F-05045 Report for Final Disposition Paper Vital Records English
DPH-05046 F-05046 Delayed Death - Court Order Paper Vital Records English
DPH-05054 F-05054 Court Order To Amend Cause of Death - 89 Paper Vital Records English
DPH-05091 F-05091 Court Order To Amend Birth Certificate Paper Vital Records English
DPH-05092 F-05092 Court Order To Amend Death Certificate Paper Vital Records English
DPH-05092T F-05092T Court Order To Amend A Tribal Related Wisconsin Death Certificate Paper Vital Records English
DPH-05093 F-05093 Court Order To Amend A Marriage Certificate Paper Vital Records English
DPH-05093T F-05093T Court Order To Amend A Tribal Related Wisconsin Marriage Certificate Paper Vital Records English
DPH-05098 F-05098 Court Order to Correct Facts, Misrepresented Information Paper Vital Records English
DPH-05102 F-05102 Wisconsin Immunization Registry Exclusion Paper Vital Records English
DPH-05103 F-05103 Facts About Your Child's Birth Certificate Paper Forms Center English
DPH-05104 F-05104 Facts About Your Child's Birth Certificate - Spanish Paper Forms Center English
DPH-05191 F-05191 Vital Records Fee Schedule Paper Forms Center English
DPH-05210 F-05210 Name Change Request Within 1st Year Paper Vital Records English
DPH-05218 F-05218 E-mail Notification Request For New Publication Release HTML None English
DPH-05260 F-05260 Letter of Non-Marriage Application PDF None English
DPH-05280 F-05280 Death Certificate Application pdf None English
DPH-05280S F-05280S Death Certificate Application - Spanish PDF None Spanish
DPH-05281 F-05281 Marriage Certificate Application - Wisconsin pdf None English
DPH-05281S F-05281S Marriage Certificate Application - Wisconsin - Spanish PDF None Spanish
DPH-05282 F-05282 Divorce Certificate Application - Wisconsin pdf None English
DPH-05282S F-05282S Divorce Certificate Application - Wisconsin - Spanish PDF None Spanish
DPH-05283 F-05283 Veterans Application Paper Vital Records English
DPH-05291 F-05291 Birth Certificate Application - Wisconsin pdf Forms Center English
DPH-05291S F-05291S Birth Certificate Application - Wisconsin - Spanish PDF None Spanish
DPH-05292 F-05292 FAX Request for Wisconsin Birth Certificate PDF None English
DPH-05292S F-05292S FAX Request for Wisconsin Birth Certificate - Spanish pdf None Spanish
DPH-05294 F-05294 FAX Request for Wisconsin Marriage Certificate PDF None English
DPH-05294S F-05294S FAX Request for Wisconsin Marriage Certificate - Spanish pdf None Spanish
DPH-05296 F-05296 FAX Request for Wisconsin Divorce Certificate PDF None English
DPH-05296S F-05296S FAX Request for Wisconsin Divorce Certificate - Spanish pdf None Spanish
DPH-05297 F-05297 FAX Request for Wisconsin Death Certificate PDF None English
DPH-05297S F-05297S FAX Request for Wisconsin Death Certificate - Spanish pdf None Spanish
HCF-09002 F-09002 Affidavit of Return or Exchange of Food Coupons pdf None English
HCF-09003 F-09003 Coupon Account and Destruction Report Paper Forms Manager English

Last Revised:  July 02, 2009