Official DHS Forms Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions. When you are searching for a document, enter the number or a portion of the title in the search box below. To narrow your search results even more, place quotation marks (" ") around search terms.

If you are looking for an informative document, visit our Informative Documents and Publications Library. If you need a file in another file format or can't find what you are looking for here, reach out to the Digital Communications Team at dhsfmorder@dhs.wisconsin.gov. You can typically expect a response within 1-2 business days.

Assigned Number Title Sort descending Division Language Release Date File Type Available to Order
F-02242 Hepatitis A High-Risk Occupations Questionnaire DPH English 11/2017 PDF
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases DPH English 03/2018 PDF
F-13148 HIPAA Privacy Access Request DMS English 07/2008 PDF
F-13149 HIPAA Privacy Accounting Request DMS English 07/2008 PDF
F-13151 HIPAA Privacy Amendment Request DMS English 07/2008 PDF
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS English 07/2008 PDF
F-13146 HIPAA Privacy Revocation of Authorization DMS English 07/2008 PDF
F-02086 Histoplasmosis Case Worksheet DPH English 04/2017 PDF
F-01359 Historical Earnings Verification Request DMS English 02/2022 Word
F-03103 HIV Care Unit Subrecipient Corrective Action Plan DPH English 11/2022 Word
F-01423S HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report, Spanish DPH Spanish 09/2021 PDF
F-03112 HMO Quarterly Appeals Log DMS English 05/2024 Excel
F-03112A HMO Quarterly Grievance Log DMS English 08/2024 Excel
F-03112AI HMO Quarterly Grievance Log Instructions DMS English 01/2024 PDF
F-03288 Home and Community-Based Non-Residential Settings Attestation DMS English 06/2024 Word
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA English 08/2021 Word
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA English 08/2021 PDF
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment DMS English 05/2017 PDF
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment DMS English 05/2017 Word
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program DMS English 06/2023 PDF
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist DQA English 11/2018 Word
F-62069 Home Health Agency Complaint Report DQA English 10/2024 Word
F-62069S Home Health Agency Complaint Report, Spanish DQA Spanish 10/2024 Word
F-62657 Home Health Agency Contract Review Worksheet DQA English 07/2008 Word
F-62657 Home Health Agency Contract Review Worksheet DQA English 07/2008 PDF
F-01710 Home Health Agency Initial Licensure Checklist DQA English 12/2016 Word
F-62674 Home Health Agency License Application DQA English 08/2023 Word
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA English 04/2009 Word
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA English 04/2009 PDF
F-01407 Home Visit Checklist DPH English 09/2024 PDF
F-01407S Home Visit Checklist, Spanish DPH Spanish 09/2024 PDF
F-03077 Home Walkthrough Checklist DPH English 06/2023 PDF
F-62236 Hospice Clinical Record Review DQA English 01/2024 Word
F-62287 Hospice Complaint Report DQA English 10/2024 Word
F-62287H Hospice Complaint Report, Hmong DQA Hmong 10/2024 Word
F-62287S Hospice Complaint Report, Spanish DQA Spanish 10/2024 Word
F-62232 Hospice Contracts and Agreements Review DQA English 01/2024 Word
F-62641 Hospice Inpatient Care DQA English 03/2024 Word
F-62322 Hospice Inpatient Clinical Record Review - Interviews DQA English 03/2024 Word
F-62062 Hospice License Application DQA English 07/2020 Word
F-62294 Hospice Multiple Location Questionnaire DQA English 09/2024 Word
F-62316 Hospice Patient Rights DQA English 10/2024 Word
F-62233 Hospice Personnel Record Review DQA English 01/2024 Word
F-62318 Hospice Quality Assessment and Performance Improvement Review DQA English 01/2024 PDF
F-62318 Hospice Quality Assessment and Performance Improvement Review DQA English 01/2024 Word
F-62320 Hospice Survey Information DQA English 03/2024 Word
F-62319 Hospice Volunteer Program Review DQA English 01/2024 Word
F-02527 Hospital (DHS 124), Home Health Agency (DHS 133), Hospice (DHS 131), Personal Care Agency (DHS 106), and Adult Day Care Center (DHS 105) DQA English 11/2022 Word
F-62092 Hospital Certificate of Approval Application DQA English 03/2024 Word
F-44725 Hospital/Clinic Supplement - Provider Participation Agreement DPH English 05/2019 Word

Glossary

 
Last revised December 4, 2024