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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-44338 Wisconsin HIV Case Report DPH English 01/2024 Word No
F-44257 Wisconsin Immunization Record Card DPH English 11/2022 PDF Yes
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH English 05/2019 PDF No
F-02487CM Wisconsin Immunization Registry (WIR) Record Release Authorization, Chinese (Simplified) DPH Chinese (Simplified) 05/2019 PDF No
F-02487HI Wisconsin Immunization Registry (WIR) Record Release Authorization, Hindi DPH Hindi 05/2019 PDF No
F-02487H Wisconsin Immunization Registry (WIR) Record Release Authorization, Hmong DPH Hmong 05/2019 PDF No
F-02487SO Wisconsin Immunization Registry (WIR) Record Release Authorization, Somali DPH Somali 05/2019 PDF No
F-02487S Wisconsin Immunization Registry (WIR) Record Release Authorization, Spanish DPH Spanish 05/2019 PDF No
F-05102 Wisconsin Immunization Registry Opt-out Request DPH English 07/2019 PDF Yes
F-03037 Wisconsin Lead-in Water Testing and Remediation (WTR) Initiative DPH English 05/2022 PDF No
F-10144 Wisconsin Life Insurance Inquiry DMS English 05/2019 Word No
F-05281 Wisconsin Marriage Certificate Application DPH English 12/2023 PDF No
F-05281S Wisconsin Marriage Certificate Application, Spanish DPH Spanish 01/2024 PDF No
F-11048 Wisconsin Medicaid - Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS English 02/2009 PDF No
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS English 08/2019 PDF No
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS English 08/2019 Word No
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS English 09/2019 Word No
F-01003 Wisconsin Medicaid Certification of Public Expenditures DMS English 07/2008 PDF No
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS English 04/2019 PDF No
F-11079A Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More Than 50 Beds)Rural Health Clinics Completion Instructions DMS English 07/2017 PDF No
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS English 08/2016 Word No
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS English 08/2016 Word No
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS English 12/2010 Word No
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS English 12/2010 PDF No
F-01009AH Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Hmong DMS Hmong 12/2010 PDF No
F-01009AH Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Hmong DMS Hmong 12/2010 Word No
F-01009AS Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Spanish DMS Spanish 12/2010 PDF No
F-01009AS Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under, Spanish DMS Spanish 12/2010 Word No
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS English 12/2010 PDF No
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS English 12/2010 Word No
F-01009BH Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Hmong DMS Hmong 12/2010 PDF No
F-01009BH Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Hmong DMS Hmong 12/2010 Word No
F-01009BS Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Spanish DMS Spanish 12/2010 Word No
F-01009BS Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older, Spanish DMS Spanish 12/2010 PDF No
F-10101 Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet DMS English 03/2024 PDF Yes
F-10101DA Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Dari DMS Dari (Afghan Persian) 03/2024 PDF No
F-10101H Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Hmong DMS Hmong 03/2024 PDF No
F-10101PA Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Pashto DMS Pashto 03/2024 PDF No
F-10101S Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, Spanish DMS Spanish 03/2024 PDF No
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS English 08/2018 PDF No
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS English 07/2008 PDF No
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election DMS English 05/2023 PDF No
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election DMS English 05/2023 Word No
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness DMS English 08/2019 PDF No
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness DMS English 08/2019 Word No
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS English 02/2017 Word No
F-00180C Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation DMS English 09/2024 Word No
F-00180CS Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation, Spanish DMS Spanish 09/2024 Word No
F-03263 Wisconsin Medicaid Provider Self-Audit Overpayment Report OIG English 01/2024 PDF No
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS English 10/2012 PDF No

Glossary

 
Last revised August 26, 2024