Skip to main content
Dot gov

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

HTTPS

Secure .gov websites use HTTPS
A lock () or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

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-02940 Enrollment Counseling Customer Survey DPH English 02/2022 HTML No
F-01655 Enrollment Discrepancy Report DMS English 08/2021 Excel No
F-03071 Environmental Services Checklist DPH English 03/2023 PDF No
F-02851 Equipment List Out of Hospital Scenario DPH English 07/2021 Word No
F-02026 Ethnicity and Race Selection DPH English 05/2020 PDF No
F-02026S Ethnicity and Race Selection, Spanish DPH Spanish 05/2020 PDF No
F-40096 eWIC Program Repayment Agreement DPH English 08/2023 PDF No
F-40096H eWIC Program Repayment Agreement, Hmong DPH Hmong 08/2023 PDF No
F-40096S eWIC Program Repayment Agreement, Spanish DPH Spanish 08/2023 PDF No
F-01835 eWIC Transaction Issue DPH English 09/2016 Word No
F-11079 Excel DMS English 10/2016 Excel No
F-01700 Exception-to-Policy Request DPH English 12/2021 Word No
F-00943 Exhibit II - Tribal Work Plan OS English 05/2023 Word No
F-01234 Explanation of Medical Benefits DMS English 04/2018 PDF No
F-01234 Explanation of Medical Benefits DMS English 04/2018 Word No
F-02296 F-02296, Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with HMOs, MCOs, and IRIS OIG English 10/2019 Word No
F-02296B F-02296B, Medicaid Fraud Control Elder Abuse Unit Referral Feedback: Used in Partnership with HMOs, MCOs, and IRIS OIG English 10/2019 Word No
F-02296C F-02296C, Medicaid Fraud Control Elder Abuse Unit Referral: Overpayment Recovery OIG English 02/2020 Word No
F-02296I F-02296i,Instructions: Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with HMOs and MCOs OIG English 10/2019 PDF No
F-02296II F-02296ii,Instructions: Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with IRIS OIG English 10/2019 PDF No
F-11023 F-11023, F-11023B, and F-11023C: Cost Report for Provider-Based Rural Health Clinics DMS English 06/2024 Excel No
F-11023BI F-11023BI: Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Instructions DMS English 06/2024 PDF No
F-11023I F-11023I: Cost Report for Provider-Based Rural Health Clinics Instructions DMS English 06/2024 PDF No
F-02500 Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care DPH English 12/2020 Word No
F-03146 Facility Request for DHS Connect Viewer Access DCTS English 05/2023 Word No
F-03215 Facility Request For DHS Connect Viewer Access DCTS English 08/2023 Word No
F-05103 Facts About Your Child's Birth Certificate DPH English 03/2024 PDF No
F-05103H Facts About Your Child's Birth Certificate, Hmong DPH Hmong 03/2024 PDF No
F-05103S Facts About Your Child's Birth Certificate, Spanish DPH Spanish 03/2024 PDF No
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS English 12/2018 Word No
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH English 02/2024 Word No
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions (DocuSign) DPH English 02/2024 HTML No
F-00221LP Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions (Large Print) DPH English 02/2024 Word No
F-00221AR Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Arabic DPH Arabic 02/2024 PDF No
F-00221CM Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Chinese (Mandarin) DPH Chinese Mandarin 02/2024 Word No
F-00221H Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Hmong DPH Hmong 02/2024 Word No
F-00221L Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Laotian DPH Laotian 02/2024 Word No
F-00221R Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Russian DPH Russian 02/2024 Word No
F-00221SE Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Serbo-Croatian DPH Serbian (Serbo-Croatian) 02/2024 Word No
F-00221SO Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Somali DPH Somali 02/2024 Word No
F-00221S Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Spanish DPH Spanish 02/2024 Word No
F-02558 Family Care Member County Notification DMS English 09/2020 Word No
F-02738 Family Care Partnership Appeal Decision Letter DMS English 10/2020 Word No
F-02739 Family Care Partnership Letter about Your Right to Make a Fast Complaint DMS English 10/2020 Word No
F-00046 Family Care Program: Enrollment DPH English 02/2024 Word No
F-00046 Family Care Program: Enrollment (DocuSign) DPH English 02/2024 HTML No
F-00046LP Family Care Program: Enrollment (Large Print) DPH English 02/2024 Word No
F-00046AR Family Care Program: Enrollment, Arabic DPH Arabic 02/2024 PDF No
F-00046CM Family Care Program: Enrollment, Chinese (Mandarin) DPH Chinese Mandarin 02/2024 Word No
F-00046H Family Care Program: Enrollment, Hmong DPH Hmong 02/2024 Word No

Glossary

 
Last revised December 8, 2023