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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-02595 Request for Approval: Youth Crisis Stabilization Facilities (YCSF) Certification Application DCTS English 10/2020 Word No
F-02733 Request for Community Spouse Signature DMS English 06/2023 PDF No
F-02733H Request for Community Spouse Signature, Hmong DMS Hmong 06/2023 PDF No
F-02733S Request for Community Spouse Signature, Spanish DMS Spanish 06/2023 PDF No
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS English 10/2016 Word No
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS English 10/2016 PDF No
F-02925 Request for HIV Care Grievance Resolution DPH English 01/2022 Word No
F-01885 Request for ImageTrend Patient Registry Access DPH English 07/2023 PDF No
F-03191 Request for ImageTrend Patient Registry Access for Additional Facilities DPH English 07/2023 PDF No
F-25527 Request for Increased Contract Allocation DCTS English 01/2017 Word No
F-02885 Request for Institution of Mental Disease Determination for Children’s Residential Settings DMS English 10/2021 PDF No
F-02885 Request for Institution of Mental Disease Determination for Children’s Residential Settings DMS English 10/2021 Word No
F-02746 Request for Institution of Mental Disease Determination for Residential Substance Use Disorder Facilities DMS English 12/2020 PDF No
F-02746 Request for Institution of Mental Disease Determination for Residential Substance Use Disorder Facilities DMS English 12/2020 Word No
F-20448 Request for Medicaid Administrative Funds - Staff Position DMS English 03/2017 Word No
F-02937 Request for Medicaid Coverage Consideration for Procedures and Devices DMS English 02/2022 HTML No
F-01020A Request for Nursing Home Care Determination Completion Instructions DMS English 02/2017 PDF No
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA English 01/2021 Word No
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA English 01/2021 PDF No
F-00330 Request for Replacement FoodShare and/or Summer EBT Benefits DMS English 10/2024 PDF No
F-00330AR Request for Replacement FoodShare and/or Summer EBT Benefits, Arabic DMS Arabic 10/2024 PDF No
F-00330CM Request for Replacement FoodShare and/or Summer EBT Benefits, Chinese (Simplified) DMS Chinese (Simplified) 10/2024 PDF No
F-00330G Request for Replacement FoodShare and/or Summer EBT Benefits, German DMS German 10/2024 PDF No
F-00330H Request for Replacement FoodShare and/or Summer EBT Benefits, Hmong DMS Hmong 10/2024 PDF No
F-00330L Request for Replacement FoodShare and/or Summer EBT Benefits, Laotian DMS Laotian 10/2024 PDF No
F-00330R Request for Replacement FoodShare and/or Summer EBT Benefits, Russian DMS Russian 10/2024 PDF No
F-00330SO Request for Replacement FoodShare and/or Summer EBT Benefits, Somali DMS Somali 10/2024 PDF No
F-00330S Request for Replacement FoodShare and/or Summer EBT Benefits, Spanish DMS Spanish 10/2024 PDF No
F-20572 Request for State Public Funding for Non-Residents DCTS English 05/2020 Word No
F-62608 Request for Use of Medical Restraints DMS English 03/2017 Word No
F-62608 Request for Use of Medical Restraints DMS English 03/2017 PDF No
F-00926A Request for Use of Medical Restraints - CLTSS DMS English 02/2017 PDF No
F-00926A Request for Use of Medical Restraints - CLTSS DMS English 02/2017 Word No
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS English 03/2017 Word No
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS English 03/2017 PDF No
F-00569 Request for Waiver of Administrative Rule for Licensure DPH English 09/2019 Word No
F-03282 Request for Waiver of Administrative Rule—Trauma Care Services DPH English 06/2024 PDF No
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS English 07/2012 Word No
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS English 07/2012 PDF No
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH English 07/2016 Word No
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH English 07/2016 Word No
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate DMS English 06/2015 PDF No
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH English 07/2016 Word No
F-02068 Request to Establish a Children's COP Risk Reserve DMS English 04/2017 Word No
F-03266 Request to Lower Your FoodShare Overpayment DMS English 02/2024 PDF No
F-03266H Request to Lower Your FoodShare Overpayment, Hmong DMS Hmong 02/2024 PDF No
F-03266S Request to Lower Your FoodShare Overpayment, Spanish DMS Spanish 02/2024 PDF No
F-02603 Request to Not Pay Your Medicaid Purchase Plan Premium for a Short Time Because of a Difficult Situation DMS English 05/2024 PDF No
F-02603H Request to Not Pay Your Medicaid Purchase Plan Premium for a Short Time Because of a Difficult Situation, Hmong DMS Hmong 05/2024 PDF No
F-02603S Request to Not Pay Your Medicaid Purchase Plan Premium for a Short Time Because of a Difficult Situation, Spanish DMS Spanish 05/2024 PDF No

Glossary

 
Last revised August 26, 2024