Find the current program-related forms for the WA State WISEWOMAN program below. All of the currently available languages are listed.

Note: These forms are only for use by providers/clinics contracted with a Prime Contractor in their region to provide WISEWOMAN. For providers looking to participate in BCCHP or patients who are looking to enroll in the program, please reach out to the prime contractor for your region. If you have any questions or concerns about these forms, please email

WISEWOMAN Participant Agreement DOH349-040
  • Amharic PDF (Oct 2021)
  • Chinese (Trad) PDF (Oct 2021)
  • English PDF (Oct 2021)
  • Korean PDF (Oct 2021)
  • Spanish PDF (Oct 2021)
  • Tigrinya PDF (Oct 2021)
  • Vietnamese PDF (Oct 2021)
Lifestyle Support Program Tracking Form DOH349-042
  • English .docx (April 2022)
Baseline/Follow-up Screening Form DOH345-361
  • English .docx (July 2023)
Risk Reduction Brochure ("My Health Info") DOH349-039
  • Amharic PDF (May 2021)
  • Chinese (Trad) PDF (May 2021)
  • English PDF (May 2021)
  • Korean PDF (May 2021)
  • Spanish PDF (May 2021)
  • Tigrinya PDF (May 2021)
  • Vietnamese PDF (May 2021)
Risk Reduction Form DOH345-363
  • English .docx (October 2022)
WISEWOMAN Services Reimbursement Billing Sheet DOH141-033
  • English .docx (June 2023)