DEPARTMENT OF HEALTH SERVICES Division of Public Health DPH 4000 (Rev. 07/08)
STATE OF WISCONSIN s. 252.10 (7), Wis Stats. (608) 266-9692 FAX: (608) 266-0049
WISCONSIN ANTITUBERCULOSIS THERAPY PROGRAM INITIAL REQUEST FOR MEDICATION
This form has been renumbered and revised. Please update your link with the following: http://dhs.wisconsin.gov/forms/F4/F44000.pdf