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Data Collection (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 form, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-00162 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS English 06/2024 PDF No
F-00162A Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids Instructions DMS English 06/2024 PDF No
F-02505 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS English 06/2024 Word No
F-02505 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS English 06/2024 PDF No
F-02505A Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors Instructions DMS English 06/2024 PDF No
F-11092 Effective for use on and after 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 06/2024 PDF No
F-11092 Effective for use on and after 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 06/2024 Word No
F-11092A Effective for use on and after 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs Instructions DMS English 06/2024 PDF No
F-00081 Effective for use on and after 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 06/2024 Word No
F-00081 Effective for use on and after 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 06/2024 PDF No
F-00081A Effective for use on and after 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine Instructions DMS English 06/2024 PDF No
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers DPH English 07/2016 Word No
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS English 04/2023 Word No
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS English 04/2023 PDF No
F-02717H Electronic Visit Verification (EVV) Live-in Worker Identification, Hmong DMS Hmong 04/2023 Word No
F-02717H Electronic Visit Verification (EVV) Live-in Worker Identification, Hmong DMS Hmong 04/2023 PDF No
F-02717S Electronic Visit Verification (EVV) Live-in Worker Identification, Spanish DMS Spanish 04/2023 PDF No
F-02717S Electronic Visit Verification (EVV) Live-in Worker Identification, Spanish DMS Spanish 04/2023 Word No
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH English 11/2022 PDF No
F-44763S Emergency Care Do Not Resuscitate Order (DNR), Spanish DPH Spanish 11/2022 PDF No
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH English 09/2019 Word No
F-02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH English 11/2019 PDF No
F-00567 Emergency Medical Services Complaint DPH English 11/2022 HTML No
F-00567 Emergency Medical Services Complaint DPH English 08/2021 PDF No
F-47255 Emergency Medical Services Program Municipal Signature and Population Verification DPH English 11/2019 PDF No
F-47472 Emergency Medical Technician (EMT) License / First Responder Certification Renewal Application DPH English 11/2009 HTML No
F-47471 Emergency Medical Technician Verification of Licensure DPH English 03/2003 HTML No
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA English 03/2013 PDF No
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA English 03/2013 Word No
F-00551 Emergency Mental Health Service Programs Initial Certification Application - DHS 34 DQA English 06/2024 Word No
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors DPH English 01/2020 PDF No
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS English 06/2019 PDF No
F-10146 Employer Verification of Earnings DMS English 02/2022 Word No
F-10146A Employer Verification of Earnings: Proof of Employment DMS English 06/2020 Word No
F-03042 Employer-Sponsored Blood Drives Grant Funding Opportunity: Application DPH English 05/2022 HTML No
F-02871 emPOWER Data Use Evaluation DPH English 09/2021 HTML No
F-00568 EMS Board Sub-Committee Appointment Application DPH English 09/2019 Word No
F-02205 EMS Instructor II Evaluation DPH English 09/2017 Word No
F-47489 EMS Patient Care Worksheet DPH English 08/2015 PDF No
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH English 05/2015 Word No
F-00987C EMS Service Operational Plan Advanced Skills Addendum (First Responder) DPH English 09/2016 Word No
F-00987A EMS Service Operational Plan Advanced Skills Addendum (Intermediate) DPH English 05/2015 Word No
F-00987D EMS Service Operational Plan Advanced Skills Addendum (Paramedic) DPH English 05/2014 Word No
F-00987 EMS Service Operational Plan, Advanced Skills Addendum (Basic) DPH English 05/2015 Word No
F-47463I EMS Service Provider Level Downgrade Operational Plan Components Checklist DPH English 09/2022 Word No
F-47463H EMS Service Provider Level Upgrade Operational Plan Components Checklist DPH English 09/2022 Word No
F-47463G EMS Service Provider Special Event Plan Application Components Checklist DPH English 09/2022 Word No
F-47463B EMT - Basic Operational Plan Components DPH English 01/2012 PDF No
F-21334 Encounter New User Request DMS English 02/2021 Word No
F-45018 English DPH English 03/2017 Word No

Glossary

 
Last revised December 8, 2023