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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 Division Language Release Date File Type Available to Order
F-01567A Letter: Request for Assignment of Medical Benefits DMS English 01/2021 Word No
F-02876 Letter: Screen Visit Not Scheduled DMS English 09/2021 Word No
F-02876H Letter: Screen Visit Not Scheduled, Hmong DMS Hmong 09/2021 Word No
F-02876S Letter: Screen Visit Not Scheduled, Spanish DMS Spanish 09/2021 Word No
F-02874 Letter: Screen Visit Scheduled DMS English 09/2021 Word No
F-02874H Letter: Screen Visit Scheduled, Hmong DMS Hmong 09/2021 Word No
F-02874S Letter: Screen Visit Scheduled, Spanish DMS Spanish 09/2021 Word No
F-02663 Letterhead - EVV Personal Identification Number (PIN) DMS English 02/2021 HTML No
F-47484 Level III Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word No
F-47484A Level IV Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word No
F-62019 License Application for Nursing Home, Intermediate Care Facility - Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA English 12/2014 Word No
F-01022 License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS English 02/2017 Excel No
F-00165E Limited English Proficiency (LEP) Customer Data Analysis Chart OLC English 12/2021 Word No
F-02731 Line List: Respiratory Virus Outbreak - Workplace Environment DPH English 10/2020 Excel No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-03036 Local and Tribal Health Department (LTHD) Antigen Test Distribution Program Participation Attestation DPH English 05/2022 PDF No
F-01802A Local Prescriber Naloxone Standing Order for Pharmacists template DPH English 12/2019 Word No
F-01573 Log of Ice Arena Air Quality DPH English 06/2015 Word No
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 09/2024 Word No
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 09/2024 PDF No
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 09/2024 PDF No
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 09/2024 Word No
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 09/2024 Word No
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 09/2024 PDF No
F-03245 Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 09/2024 Word No
F-03245 Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 09/2024 PDF No
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 09/2024 PDF No
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 09/2024 Word No
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 09/2024 Word No
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 09/2024 PDF No
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation DMS English 09/2024 PDF No
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation DMS English 09/2024 Word No
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation DMS English 09/2024 Word No
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation DMS English 09/2024 PDF No
F-03238 Long-Term Care (LTC) Waiver Supported Employment Attestation DMS English 09/2024 Word No
F-03238 Long-Term Care (LTC) Waiver Supported Employment Attestation DMS English 09/2024 PDF No
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation DMS English 09/2024 Word No
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation DMS English 09/2024 PDF No
F-03240 Long-Term Care (LTC) Waiver Transportation Attestation DMS English 09/2024 Word No
F-03240 Long-Term Care (LTC) Waiver Transportation Attestation DMS English 09/2024 PDF No
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation DMS English 09/2024 Word No
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation DMS English 09/2024 PDF No
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation DMS English 09/2024 Word No
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation DMS English 09/2024 PDF No
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA English 06/2024 Word No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 Word No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 PDF No
F-01567S Long-Term Care Insurance Policy - Assignment of Benefits, Spanish DMS Spanish 12/2018 PDF No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised December 4, 2024