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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-13149 HIPAA Privacy Accounting Request DMS English 07/2008 PDF No
F-13151 HIPAA Privacy Amendment Request DMS English 07/2008 PDF No
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS English 07/2008 PDF No
F-13146 HIPAA Privacy Revocation of Authorization DMS English 07/2008 PDF No
F-02086 Histoplasmosis Case Worksheet DPH English 04/2017 PDF No
F-01359 Historical Earnings Verification Request DMS English 02/2022 Word No
F-03103 HIV Care Unit Subrecipient Corrective Action Plan DPH English 11/2022 Word No
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH English 01/2025 PDF No
F-01423S HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report, Spanish DPH Spanish 01/2025 PDF No
F-44614B HIV Drug Assistance Program and Insurance Assistance Program Application/Recertification Part B – Physician Portion DPH English 01/2025 PDF No
F-44614BS HIV Drug Assistance Program and Insurance Assistance Program Application/Recertification Part B – Physician Portion, Spanish DPH Spanish 01/2025 PDF No
F-44614A HIV Drug Assistance Program and Insurance Assistance Program Application/Recertification – Part A DPH English 01/2025 PDF No
F-44614AS HIV Drug Assistance Program and Insurance Assistance Program Application/Recertification – Part A, Spanish DPH Spanish 01/2025 PDF No
F-03112 HMO Quarterly Appeals Log DMS English 02/2025 Excel No
F-03112A HMO Quarterly Grievance Log DMS English 02/2025 Excel No
F-03112AI HMO Quarterly Grievance Log Instructions DMS English 01/2024 PDF No
F-03288 Home and Community-Based Non-Residential Settings Attestation DMS English 06/2024 Word No
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA English 08/2021 Word No
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA English 08/2021 PDF No
F-20445B Home and Community-Based Services (HCBS) Settings Rule Modification Questionnaire – Children’s Long-Term Support (CLTS) Waiver Program DMS English 02/2025 Word No
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment DMS English 05/2017 PDF No
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment DMS English 05/2017 Word No
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program DMS English 06/2023 PDF No
F-02319H Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program, Hmong DMS Hmong 06/2023 PDF No
F-02319S Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program, Spanish DMS Spanish 06/2023 PDF No
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist DQA English 11/2018 Word No
F-62069 Home Health Agency Complaint Report DQA English 10/2024 Word No
F-62069S Home Health Agency Complaint Report, Spanish DQA Spanish 10/2024 Word No
F-62657 Home Health Agency Contract Review Worksheet DQA English 07/2008 Word No
F-62657 Home Health Agency Contract Review Worksheet DQA English 07/2008 PDF No
F-01710 Home Health Agency Initial Licensure Checklist DQA English 12/2016 Word No
F-62674 Home Health Agency License Application DQA English 08/2023 Word No
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA English 04/2009 Word No
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA English 04/2009 PDF No
F-01407 Home Visit Checklist DPH English 09/2024 PDF No
F-01407S Home Visit Checklist, Spanish DPH Spanish 09/2024 PDF No
F-03077 Home Walkthrough Checklist DPH English 06/2023 PDF No
F-62236 Hospice Clinical Record Review DQA English 01/2024 Word No
F-62287 Hospice Complaint Report DQA English 10/2024 Word No
F-62287H Hospice Complaint Report, Hmong DQA Hmong 10/2024 Word No
F-62287S Hospice Complaint Report, Spanish DQA Spanish 10/2024 Word No
F-62232 Hospice Contracts and Agreements Review DQA English 01/2024 Word No
F-62641 Hospice Inpatient Care DQA English 03/2024 Word No
F-62322 Hospice Inpatient Clinical Record Review - Interviews DQA English 03/2024 Word No
F-62062 Hospice License Application DQA English 07/2020 Word No
F-62294 Hospice Multiple Location Questionnaire DQA English 09/2024 Word No
F-62316 Hospice Patient Rights DQA English 10/2024 Word No
F-62233 Hospice Personnel Record Review DQA English 01/2024 Word No
F-62318 Hospice Quality Assessment and Performance Improvement Review DQA English 01/2024 PDF No
F-62318 Hospice Quality Assessment and Performance Improvement Review DQA English 01/2024 Word 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.

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Last revised December 4, 2024