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Forms: Numeric List - DLTC
Division of Long Term Care

This numeric list contains forms that are available from this site.  A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms. Microsoft Word - Fillable or Excel forms, can be filled in, saved, and transmitted electronically.  You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Key word explanations for Form Type and Other Location columns.

Division Prefix / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
DLTC F-00004 Health and Employment Counseling Application Word None English
DLTC F-00004A Health and Employment Counseling - I Think I Need More Time (PDF, 35 KB) PDF None English
DLTC F-00004B Health and Employment Counseling - I Have Reached Employment (PDF, 23 KB) PDF None English
DLTC F-00010 Risk Agreement - Participant Word None English
DLTC F-00022 ForwardHealth Nursing Home Rate Administrative Review Request (PDF, 12 KB) PDF None English
DLTC F-00022A ForwardHealth Nursing Home Rate Administrative Review Request Completion Instructions (PDF, 17 KB) PDF None English
DLTC/DMHSAS F-00037 Functional Screen Listserv Sign-Up HTML None English
DLTC F-00037A Expanding Adults-at-Risk in Wisconsin Listserv Sign-Up HTML None English
DLTC/DMHSAS F-00037C DLTC and DMHSAS Memo Series E-Mail Subscription Services Sign-Up HTML None English
DLTC F-00037F Virtual PACE Program - Listserv Sign-Up HTML None English
DLTC F-00037G ADRC Quality Improvement Listserv HTML None English
DLTC F-00043 Communication to Local Educational Agency Regarding Child Referral Word None English
DLTC F-00046 Family Care Program Enrollment Instructions and Important Information Word None English
DLTC F-00050 Oral Health Preliminary Exam and Prevention Services (PDF, 43 KB) PDF None English
DLTC F-00052 Aging and Disability Resource Center (ADRC) Application Word None English
DLTC F-00052A Aging and Disability Resource Center (ADRC) Annual Budget Excel None English
DLTC F-00052B CARES Data Access and Use Agreement (ADRC) Word None English
DLTC F-00053 Notice of Intent to Submit an Application (ADRC) Word None English
DLTC F-00054 Request for Waiver of Education / Experience Requirements (ADRC) Word None English
DLTC F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and MCO or ADRC and Care Management Staff Word None English
DLTC F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC Word None English
DLTC F-00054D Request for Waiver of the .5 Full-Time Equivalent Requirement for ADRC Staff Word None English
DLTC F-00054E Request for Waiver of Education / Experience Requirements - TADRS Word None English
DLTC F-00067 PROAct - Program Review Outcome / Activity Person-Centered Field Review Report Word None English
DLTC F-00075 IRIS (Include, Respect, I Self-Direct) Referral / Authorization Word None English
DLTC F-00075S IRIS (Include, Respect, I Self-Direct) Referral / Authorization - Spanish Word None Spanish
DLTC F-00076 Variance Request - Wait List (PDF, 24 KB) PDF None English
DLTC F-00076 Variance Request - Wait List Word None English
DLTC F-00102 Children's Long-Term Support Waivers HSRS Slot Change Request (PDF, 34 KB) PDF None English
DLTC F-00102 Children's Long-Term Support Waivers HSRS Slot Change Request Word None English
DLTC F-00113 Four Conditions for the Use of Funding in a CBRF Word None English
DLTC F-00152 MCO Request to Pay Over the Medicaid Fee-for-Service Reimbursement Rate Word None English
DLTC F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request Excel None English
DLTC F-00169 Opting Out of LEA Notification (PDF, 16 KB) PDF None English
DLTC F-00169S Opting Out of LEA Notification - Spanish (PDF, 22 KB) PDF None Spanish
DLTC F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies Word None English
DLTC F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers Word None English
DLTC F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports Word None English
DLTC F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program Word None English
DLTC F-00221 Family Care / IRIS Member Requested Disenrollment Word None English
DLTC F-00221A Family Care / Partnership / PACE / IRIS - Disenrollment Routing Word None English
DLTC F-00221Ai Family Care / Partnership / PACE / IRIS - Disenrollment Routing - Instructions (PDF, 19 KB) PDF None English
DLTC F-00221B Family Care / Partnership / PACE / IRIS - Refusal to Accept Services and MCO Requested Disenrollment Routing Word None English
DLTC F-00221i Family Care / IRIS Member Requested Disenrollment - Instructions (PDF, 26 KB) PDF None English
DLTC F-00236 Request for a State Fair Hearing Word None English
DLTC F-00236A Request for a State Fair Hearing - ADRC Word None English
DLTC F-00236B Request for a State Fair Hearing - IRIS Word None English
DLTC F-00237 Appeal Request - MCOs Word None English
DLTC F-00252 Work Incentive Benefits Counseling Project - Prior Authorization Word None English
DLTC F-00265 Family Care Centralized Enrollment Spreadsheet Excel None English
DLTC F-00272 WisTech Assistive Technology Advisory Council Member Application Word None English
DLTC F-00295 Medical and Remedial Expenses Checklist - Update Word None English
DLTC F-00299 Bedhold Billing Occupancy Test Worksheet Excel None English
DLTC F-00315 Written Prior Notice - Birth to 3 (PDF, 14 KB) PDF Form Center English
DLTC F-00315 Written Prior Notice - Birth to 3 Word Form Center English
DLTC F-00315A Written Prior Notice - No Evaluation - Birth to 3 (PDF, 12 KB) PDF None English
DLTC F-00315A Written Prior Notice - No Evaluation - Birth to 3 Word None English
DLTC F-00315AS Written Prior Notice - No Evaluation - Birth to 3 - Spanish (PDF, 16 KB) PDF None Spanish
DLTC F-00315B Transition Written Prior Notice - Birth to 3 (PDF, 51 KB) PDF None English
DLTC F-00315B Transition Written Prior Notice - Birth to 3 Word None English
DLTC F-00315BS Transition Written Prior Notice - Birth to 3 - Spanish (PDF, 18 KB) PDF None Spanish
DLTC F-00315C Prior Notice and Consent for Evaluation - Birth to 3 (PDF, 18 KB) PDF None English
DLTC F-00315C Prior Notice and Consent for Evaluation - Birth to 3 Word None English
DLTC F-00315CS Prior Notice and Consent for Evaluation - Birth to 3 - Spanish (PDF, 21 KB) PDF None Spanish
DLTC F-00315D Written Prior Notice - Additional Assessments Recommended (PDF, 14 KB) PDF None English
DLTC F-00315D Written Prior Notice - Additional Assessments Recommended Word None English
DLTC F-00315DS Written Prior Notice - Additional Assessments Recommended - Spanish (PDF, 15 KB) PDF None Spanish
DLTC F-00315S Written Prior Notice - Birth to 3 - Spanish (PDF, 16 KB) PDF None Spanish
DLTC F-00316 Child Status Regarding Birth to 3 Program Word None English
DLTC F-00316S Child Status Regarding Birth to 3 Program - Spanish Word None Spanish
DLTC F-00317 Early Intervention Team Report - Eligibility Determination - Birth to 3 (PDF, 28 KB) PDF None English
DLTC F-00317 Early Intervention Team Report - Eligibility Determination - Birth to 3 Word None English
DLTC F-00317S Early Intervention Team Report - Eligibility Determination - Birth to 3 - Spanish Word None Spanish
DLTC F-00321 OBVI Initial Interview Assessment Word None English
DLTC F-00334 Money Follows the Person (MFP) - Participant Reporting (PDF, 57 KB) PDF None English
DLTC F-00334 Money Follows the Person (MFP) - Participant Reporting Word None English
DLTC F-00366 Wisconsin Adult Long Term Care Functional Screen (PDF, 132 KB) PDF None English
DLTC F-00367 Children's Long Term Support (CLTS) Programs Functional Screen (FS) (PDF, 163 KB) PDF None English
DLTC F-00367A CLTS FS, Age-Specific ADL / IADL, Birth to 6 Months (PDF, 23 KB) PDF None English
DLTC F-00367B CLTS FS, Age-Specific ADL / IADL, 6 to 12 Months (PDF, 24 KB) PDF None English
DLTC F-00367C CLTS FS, Age-Specific ADL / IADL, 12 to 18 Months (PDF, 25 KB) PDF None English
DLTC F-00367D CLTS FS, Age-Specific ADL / IADL, 18 to 24 Months (PDF, 24 KB) PDF None English
DLTC F-00367E CLTS FS, Age-Specific ADL / IADL, 24 to 36 Months (PDF, 28 KB) PDF None English
DLTC F-00367F CLTS FS, Age-Specific ADL / IADL, 36 Months to 4 Years (PDF, 30 KB) PDF None English
DLTC F-00367G CLTS FS, Age-Specific ADL / IADL, 4 to 6 Years (PDF, 29 KB) PDF None English
DLTC F-00367H CLTS FS, Age-Specific ADL / IADL, 6 to 9 Years (PDF, 32 KB) PDF None English
DLTC F-00367i CLTS FS, Age-Specific ADL / IADL, 9 to 12 Years (PDF, 31 KB) PDF None English
DLTC F-00367J CLTS FS, Age-Specific ADL / IADL, 12 to 14 Years (PDF, 32 KB) PDF None English
DLTC F-00367K CLTS FS, Age-Specific ADL / IADL, 14 to 18 Years (PDF, 33 KB) PDF None English
DLTC F-00367L CLTS FS, Age-Specific ADL / IADL, 18 Years and Up (PDF, 34 KB) PDF None English
DLTC F-00388 County Birth to 3 Fiscal Reconciliation Report Word None English
DLTC F-00388i County Birth to 3 Fiscal Reconciliation Report - Instructions Word None English
DLTC F-00389 Birth to 3 Program Provider Report of Revenue Word None English
DLTC F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan Word None English
DLTC F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information Word None English
DLTC F-00478 Quality of Life Survey - Money Follows the Person (MFP) (PDF, 59 KB) PDF None English
DLTC F-00478 Quality of Life Survey - Money Follows the Person (MFP) Word None English
DLTC F-00479 Child Outcomes Fidelity Self-Assessment Word None English
DLTC F-00480 Child Outcomes Summary Word None English
DLTC F-00528 Elder Abuse Direct Service Funds Application (PDF, 14 KB) PDF None English
DLTC F-00528 Elder Abuse Direct Service Funds Application Word None English
DLTC F-00533 PACE / Partnership Programs - Enrollment Word None English
DLTC F-00534 PACE / Partnership Member Requested Disenrollment Word None English
DLTC F-00534i PACE / Partnership Member Requested Disenrollment - Instructions (PDF, 19 KB) PDF None English
DLTC F-00539 Children's Long Term Support Service Coordination Rate Worksheet Excel None English
DLTC F-00543A Self-Assessment/On-Site File Review Checklist (PDF, 63 KB) PDF None English
DLTC F-00543A Self-Assessment/On-Site File Review Checklist Word None English
DLTC F-00558 Self-Assessment Summary Word None English
DLTC F-00565 Program in Partnership Plan - PIPP Word None English
DLTC F-00575 Notice of Intent to Submit an Application for Tribal Aging & Disability Resource Specialist (TADRS) Word None English
DLTC F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application Word None English
DLTC F-00576A Tribal Aging and Disability Resource Specialist (TADRC) Annual Budget Excel None English
DLTC F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System Word None English
DES F-00603 PPS (Program Participation System) Core Module Word None English
DLTC F-00603i Program Participation System Core Instructions (PDF, 67 KB) PDF None English
DLTC F-00615 Change Project Report Word None English
DLTC F-00632 Consent to Access Private Insurance and/or Medicaid (PDF, 22 KB) PDF None English
DLTC F-00632 Consent to Access Private Insurance and/or Medicaid Word None English
DLTC F-00632_ Birth to 3 Program System of Payments and Consent to Access Private Insurance and/or Medicaid, FORM & PUBLICATION (PDF, 35 KB) PDF None English
DLTC F-00632_ Birth to 3 Program System of Payments and Consent to Access Private Insurance and/or Medicaid, FORM & PUBLICATION Word None English
DLTC F-00632S Birth to 3 Program System of Payments and Consent to Access Private Insurance and Medicaid Spanish (PDF, 42 KB) PDF None Spanish
DLTC F-00632S Birth to 3 Program System of Payments and Consent to Access Private Insurance and Medicaid Spanish Word None Spanish
DLTC F-00633 Notice and Consent for Screening (PDF, 85 KB) PDF None English
DLTC F-00633 Notice and Consent for Screening Word None English
DLTC F-00633s Notice and Consent for Screening - Spanish (PDF, 100 KB) PDF None Spanish
DLTC F-00676 Youth Transition Pre-Test Word None English
DLTC F-00676A Youth Transition Post-Test Word None English
DLTC F-00681 Partnership - Managed Care Organization (MCO) Options Word None English
DLTC F-00681A Family Care - Managed Care Organization (MCO) Options Word None English
DLTC F-00688 Consent to Release Medical and Birth-3 Information/Referral to Birth-3 Word None English
DLTC F-00695 Connections to Community Living Non-MDS Referral and Tracking Word None English
DLTC F-00777 MAPT Vendor Related Allocation Formula Word None English
DLTC F-00780 Options Counseling Tip Card Paper Form Center English
DLTC F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report Word None English
DLTC F-00888 Next Steps (PDF, 89 KB) Paper Form Center English
DLTC F-00889 Designation of Confidential and Proprietary Information- Managed LTC Business Plan (PDF, 46 KB) PDF None English
DLTC F-00889 Designation of Confidential and Proprietary Information- Managed LTC Business Plan Word None English
DLTC F-00915 Wisconsin Birth to 3 Program - Data Discussion Evaluation Word None English
DLTC F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance Word None English
DLTC F-00926 Request for Use of Restraints, Isolation, or Protective Equipment - CLTS (PDF, 49 KB) PDF None English
DLTC F-00926 Request for Use of Restraints, Isolation, or Protective Equipment - CLTS Word None English
DLTC F-00926A Request for Use of Medical Restraints – CLTS (PDF, 51 KB) PDF None English
DLTC F-00926A Request for Use of Medical Restraints – CLTS Word None English
DLTC F-00942 Meet our "Henry" Word None English
DLTC F-00950 CMS 10003-NDMCP, Notice of Denial of Medical Coverage Word None English
DLTC F-00950i Instructions - CMS 10003-NDMCP, Notice of Denial of Medical Coverage Word None English
DLTC F-00963 Children’s Long Term Support Reconciliation Packet Excel None English
HCF-01020 F-01020 ForwardHealth - Wisconsin Medicaid Request for Nursing Home Care Determination (PDF, 27 KB) PDF None English
HCF-01020 F-01020 ForwardHealth - Wisconsin Medicaid Request for Nursing Home Care Determination Word None English
HCF-01020A F-01020A ForwardHealth - Wisconsin Medicaid Request for Nursing Home Care Determination Completion Instructions (PDF, 26 KB) PDF None English
HCF-01022A-E F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease Excel None English
HCF-01104 F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster Excel None English
HCF-01147 F-01147 Notice of Intent - Chapter 150 Program, Long Term Care / Resource Allocation Program Word None English
HCF-01148 F-01148 Chapter 150 Program, Application for Renewing the Approval of a Distinct Part Facility for the Developmentally Disabled (FDD) Word None English
DLTC F-01200 IRIS Program Cost Share Repayment Agreement Word None English
DLTC F-01203 IRIS Provider Education—Health and Safety – Incident Reporting Word None English
DLTC F-01205 IRIS Participant Education—Self-Direction Responsibilities Word None English
DLTC F-01205A IRIS Participant Education--Health and Safety - Incident Reporting Word None English
DLTC F-01205B IRIS Participant Education--Budget Amendment Process Word None English
DLTC F-01205C IRIS Participant Education--One-Time Expense Process Word None English
DLTC F-01206 IRIS One-Time Expense Request Word None English
DLTC F-01206A IRIS One-Time Expense Vendor Bid Comparison Word None English
DLTC F-01207 IRIS Fiscal/Employer Agent Quality Management Plan Word None English
DLTC F-01208 IRIS Consultant Agency Quality Management Plan Word None English
DLTC F-01209 IRIS Certification Acknowledgment Word None English
DLTC F-01210 IRIS Budget Amendment Request Word None English
DLTC F-01210A IRIS Budget Amendment Provider Quote Comparison Word None English
HCF-01812 F-01812 Wisconsin Medicaid Program Nursing Home Cost Report (PDF, 512 KB) PDF None English
HCF-01812A F-01812A Wisconsin Medicaid Program Nursing Home Cost Report Instructions (PDF, 544 KB) PDF None English
HCF-01813 F-01813 Patients by Payer Source on Last Day of Quarter Excel None English
DDE-0009 F-20009 Complaint Report (PDF, 10 KB) PDF None English
DDE-0224 F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation Word None English
DDE-0394 F-20394 CIP II Community Relocation Initiative 30-day / 90-day Questionnaire Word None English
DDE-0397 F-20397 Telecommunications Assistance Program (TAP) Voucher Paper Program English
DDE-0415 F-20415 CIP II Nursing Home Diversion Request Coversheet Word None English
DDE-0418 F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool (PDF, 52 KB) PDF None English
DDE-0418 F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool Word None English
DDE-0439 F-20439 Adult Family Home (AFH) Renewal of Certification - Grandfathering Request (PDF, 45 KB) PDF None English
DDE-0439 F-20439 Adult Family Home (AFH) Renewal of Certification - Grandfathering Request Word None English
DDE-0441 F-20441 Wisconsin Incident Tracking System for Elder Abuse Reporting System None English
DDE-0441A F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection (PDF, 21 KB) PDF None English
DDE-0441AI F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values (PDF, 24 KB) PDF None English
DDE-0445 F-20445 Individual Service Plan - MA Waivers (PDF, 78 KB) PDF None English
DDE-0445 F-20445 Individual Service Plan - Medicaid Waivers Word None English
DDE-0445A F-20445A Individual Service Plan - Individual Outcomes (PDF, 39 KB) PDF None English
DDE-0445A F-20445A Individual Service Plan - Individual Outcomes Word None English
DDE-0445I F-20445i Instructions - Individual Service Plan - Medicaid Waivers (PDF, 34 KB) PDF None English
DDE-0448 F-20448 Request for Medicaid Administrative Funds Word None English
DDE-0452 F-20452 Criteria for High Risk of Nursing Home Admission (PDF, 77 KB) PDF None English
DDE-0465 F-20465 Declaration of Income (PDF, 32 KB) PDF None English
DDE-0465S F-20465S Declaration of Income - Spanish (PDF, 35 KB) PDF None Spanish
DDE-0483 F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request (PDF, 16 KB) PDF None English
DDE-0483 F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request Word None English
DDE-0582 F-20582 Application for Katie Beckett Program Wisconsin Medicaid Word None English
DDE F-20582A Application for Wisconsin’s Children's Long Term Support Programs Word None English
DDE-0582I F-20582i Application for Katie Beckett Program Wisconsin Medicaid, Instructions (PDF, 23KB) PDF None English
DDE F-20582iA Application for Wisconsin’s Children's Long Term Support Programs, Instructions (PDF, 27KB) PDF None English
DDE-0582IH F-20582iH Application for Katie Beckett Program Wisconsin Medicaid, Instructions - Hmong (PDF, 33 KB) PDF None Hmong
DDE-0582IS F-20582iS Application for Katie Beckett Program Wisconsin Medicaid, Instructions - Spanish (PDF, 36 KB) PDF None Spanish
DDE-0585 F-20585 Recertification for Wisconsin Medicaid Katie Beckett Program Word None English
DDE-0585C F-20585C Recertification for Wisconsin Medicaid, Katie Beckett Program - Short Form Word None English
DDE-0585CI F-20585ci Recertification for Wisconsin Medicaid, Katie Beckett Program - Short Form Instructions (PDF, 20KB) PDF None English
DDE-0585I F-20585i Recertification for Wisconsin Medicaid Katie Beckett Program, Instructions (PDF, 21 KB) PDF None English
DDE-0810 F-20810 Medicaid Waiver Program Health Report (PDF, 52 KB) PDF None English
DDE-0810 F-20810 Medicaid Waiver Program Health Report Word None English
DDE-0823 F-20823 COP Functional Screen (PDF, 134 KB) PDF Form Center English
DDE-0851 F-20851 Family Support Program Functional Screen (PDF, 26 KB) PDF None English
DDE-0851A F-20851A Family Support Program Functional Screen - Newborns and Young Infants (PDF, 11 KB) PDF None English
DDE-0851B F-20851B Family Support Program Functional Screen - Older Infants and Toddlers (PDF, 11 KB) PDF None English
DDE-0851C F-20851C Family Support Program Functional Screen - Pre-School Children (PDF, 11 KB) PDF None English
DDE-0851D F-20851D Family Support Program Functional Screen - School Age Children (PDF, 11 KB) PDF None English
DDE-0851E F-20851E Family Support Program Functional Screen - Young Adolescents (PDF, 11 KB) PDF None English
DDE-0851F F-20851F Family Support Program Functional Screen Older Adolescents (PDF, 11 KB) PDF None English
DDE-0851G F-20851G Family Support Program Functional Screen Screening for Severe Emotional Disturbance (All Ages) (PDF, 17 KB) PDF None English
DDE-0906 F-20906 Alzheimer's Family and Caregiver Support Program Annual Fiscal Report* System None English
DDE-0911 F-20911 Children's Long-Term Support Waivers, Intensive In-Home Autism Treatment Services: Rights, Responsibilities and Requirements (PDF, 22 KB) PDF None English
DDE-0911H F-20911H Children's Long-Term Support Waivers, Intensive In-Home Autism Treatment Services: Rights, Responsibilities and Requirements - Hmong (PDF, 22 KB) PDF None Hmong
DDE-0911S F-20911S Children's Long-Term Support Waivers, Intensive In-Home Autism Treatment Services: Rights, Responsibilities and Requirements - Spanish (PDF, 20 KB) PDF None Spanish
DDE-0919 F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet (PDF, 40 KB) PDF None English
DDE-0919 F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet Word None English
DDE-0919D F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program (PDF, 28 KB) PDF None English
DDE-0919D F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program Word None English
DDE-0920 F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care Excel None English
DDE-0920 F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care (PDF, 22 KB) PDF None English
DDE-0922 F-20922 Determination of No Active Treatment (NAT) Rating (PDF, 14 KB) PDF None English
DDE-0941 F-20941 Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration (PDF, 30 KB) PDF None English
DDE-0941 F-20941 Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration Word None English
DDE-0941A F-20941A Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration--For Counties Converting to Managed Care (PDF, 39 KB) PDF None English
DDE-0941 F-20941S Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration - Spanish (PDF, 32 KB) PDF None Spanish
DDE-0941 F-20941S Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration - Spanish Word None Spanish
DDE-0946 F-20946 Recertification Assurance--COP-W / CIP II Word None English
DDE-0971 F-20971 Documentation of Training - Supportive Home Care (SHC) / Respite Word None English
DDE-0980 F-20980 Assessment/Supplement to the Long Term Care Functional Screen Word None English
DDE-0985 F-20985 Participant Rights and Responsibilities Notification (PDF, 25 KB) PDF None English
DDE-0985H F-20985H Participant Rights and Responsibilities Notification - Hmong (PDF, 49 KB) PDF None Hmong
DDE-0985S F-20985S Participant Rights and Responsibilities Notification - Spanish (PDF, 50 KB) PDF None Spanish
DDE-0987 F-20987 Authorized Representative Designation, Medicaid Community Waiver Programs (PDF, 21 KB) PDF None English
DLTC F-20987S Authorized Representative Designation, Medicaid Community Waiver Programs - Spanish (PDF, 21 KB) PDF None Spanish
DDE-1042 F-21042 Medicaid Denial Chart (PDF, 16 KB) PDF None English
DDE-1042 F-21042 Medicaid Denial Chart Word None English
DDE-1051 F-21051 Community Long Term Care Services Referral to Income Maintenance Worker (PDF, 30 KB) PDF None English
DDE-1051 F-21051 Community Long Term Care Services Referral to Income Maintenance Worker Word None English
DDE-1055 F-21055 Home Modification Request for a Ramp (PDF, 26 KB) PDF None English
DDE-1055 F-21055 Home Modification Request for a Ramp Word None English
DDE-1056 F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution (PDF, 20 KB) PDF None English
DDE-1056 F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution Word None English
DDE-1059 F-21059 Variance Request for Institutional Respite (PDF, 14 KB) PDF None English
DDE-1059 F-21059 Variance Request for Institutional Respite Word None English
DDE-1063 F-21063 Exception to Care Management/Support and Service Coordination Contact Requirements (PDF, 14 KB) PDF None English
DDE-1063 F-21063 Exception to Care Management/Support and Service Coordination Contact Requirements Word None English
DDE-1072 F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting Word None English
DDE-1076 F-21076 Informed Consent - Children's Long-Term Support Functional Screen Word None English
DLTC F-21076H Informed Consent - Children's Long-Term Support Functional Screen - Hmong Word None Hmong
DLTC F-21076S Informed Consent - Children's Long-Term Support Functional Screen - Spanish Word None Spanish
DDE-1077 F-21077 Autism Treatment Services Criteria Checklist Instructions Word None English
DDE-1078 F-21078 Children's Long-Term Support Waivers Recertification Checklist Word None English
DDE-1080 F-21080 Children's Long-Term Support Waivers Eligibility Verification - Step One Word None English
DLTC F-21080A Children's Long-Term Support Waivers Application Checklist - Step Two Word None English
DDE-1150 F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers Word None English
DLTC F-21225 Program Participation System (PPS): B-3 Module System None English
DDE-1225A F-21225A Program Participation System (PPS): B-3 Module (PDF, 52 KB) PDF None English
DDE-1225A F-21225A Program Participation System (PPS): B-3 Module Word None English
DDE-1225AI F-21225Ai Program Participation System (PPS): B-3 Module - Deskcard (PDF, 41 KB) PDF None English
DDE-1232 F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet Word None English
DDE-1284 F-21284 Clinician Confirmation of Diagnosis Word None English
DLTC F-21334 Encounter New User Request Word None English
DLTC F-21336 Consent for Exchange of Information with Local Educational Agency Word None English
DLTC F-21336S Consent for Exchange of Information with Local Educational Agency - Spanish Word None Spanish
DDE-1343 F-21343 Alzheimer's Family and Caregiver Support Program Budget Report System None English
DLTC F-21343A Alzheimer's Family and Caregiver Support Program Financial Eligibility Screen - Worksheet 1 Word None English
DLTC F-21343B Alzheimer's Family and Caregiver Support Program Financial Eligibility Determination - Worksheet 2 Word None English
DLTC F-21343C Alzheimer's Family and Caregiver Support Program Cost-Share Calculation - Worksheet 3 Word None English
DLTC F-21343D Alzheimer's Family and Caregiver Support Program Actual County Service Payment - Worksheet 4 Word None English
DLTC F-21343E Alzheimer's Family and Caregiver Support Program - General Information Word None English
DLTC F-21343I Alzheimer's Family and Caregiver Support Program - Instructions (PDF, 41 KB) PDF None English
DDE-1353 F-21353 Community Options Program (COP) Exceptional Expense Request Word None English
DDE-2433 F-22433 Request for a Hearing, Wisconsin Birth to 3 Program (PDF, 12 KB) PDF None English
DDE-2433 F-22433 Request for a Hearing, Wisconsin Birth to 3 Program Word None English
DDE-2433 F-22433S Request for a Hearing, Wisconsin Birth to 3 Program - Spanish (PDF, 17 KB) PDF None English
DDE-2433 F-22433S Request for a Hearing, Wisconsin Birth to 3 Program - Spanish Word None Spanish
DDE-2468 F-22468 Application For Services Office For The Blind and Visually Impaired PDF None English
DDE-2468 F-22468 Application For Services Office For The Blind and Visually Impaired Word None English
DDE-2469 F-22469 Referral For OBVI Services Word None English
DDE-2491 F-22491 Consumer Report - OBVI Word None English
DDE-2538 F-22538 Consent to Film or Tape (PDF, 12 KB) PDF None English
DDE-2538 F-22538 Consent to Film or Tape Word None English
DDE-2538S F-22538S Consent to Film or Tape - Spanish (PDF, 12 KB) PDF None Spanish
DDE-2538S F-22538S Consent to Film or Tape - Spanish (PDF, 12 KB) Word None Spanish
DDE-2541 F-22541 Incident Report - Medicaid Waiver Programs (PDF, 58 KB) PDF None English
DDE-2541 F-22541 Incident Report - Medicaid Waiver Programs Word None English
DLTC F-22541i Incident Reporting - Medicaid Waiver Programs, Instructions (PDF, 51 KB) PDF None English
DDE-2550 F-22550 Birth to 3 Program Parental Cost Share (PDF, 14 KB) PDF None English
DDE-2550 F-22550 Birth to 3 Program Parental Cost Share Word None English
DDE-2550S F-22550S Birth to 3 Program Parental Cost Share - Spanish (PDF, 17 KB) PDF None Spanish
DDE-2553A F-22553A Free In-Service or Educational Training Request (PDF, 35 KB) PDF None English
DDE-2554 F-22554 Hearing Loss Certification Telecommunications Assistance Program* (PDF, 20 KB) PDF None English
DDE-2568 F-22568 Elder Abuse Direct Service Expenditures System None English
DDE-2605 F-22605 Transfer for Protective Placement (PDF, 11 KB) PDF None English
DDE-2605 F-22605 Transfer for Protective Placement Word None English
DDE-2637 F-22637 Interagency Notification -Termination of Community Waiver Participation (PDF, 18 KB) PDF None English
DDE-2638 F-22638 Notification of Waiver Program Termination (PDF, 14 KB) PDF None English
DDE-2638 F-22638 Notification of Waiver Program Termination Word None English
DLTC F-22638S Notification of Waiver Program Termination - Spanish Word None Spanish
DDE-2640 F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) (PDF, 17 KB) PDF None English
DDE-2640 F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) Word None English
DDE-2678 F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate (PDF, 103 KB) PDF None English
DDE-2678 F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate Word None English
DDE-2683 F-22683 MAPT Time Study Excel None English
DDE-4277 F-24277 Informed Consent for Medication IF ABLE, PRINT BACK-TO-BACK Word None English
DDE-4277 BRD F-24277 BRD Informed Consents for Medications: Brand Name Index IF ABLE, PRINT BACK-TO-BACK Word None English
DDE-4277 GEN F-24277 GEN Informed Consents for Medications: Generic Name Index IF ABLE, PRINT BACK-TO-BACK Word None English
DMHSAS F-24277_Sp Informed Consent for Medication, Spanish IF ABLE, PRINT BACK-TO-BACK Word None Spanish
DDE-6003 F-26003 Letter - Notice of Privacy Practices - Treatment Facilities - HCC (PDF, 80 KB) PDF None English
DDE-6003 F-26003 Letter - Notice of Privacy Practices - Treatment Facilities - HCC Word None English
DDE-6003 F-26003A Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC (PDF, 78 KB) PDF None English
DDE-6003 F-26003A Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC Word None English
DDE-6003H F-26003AH Letter - Notice of Privacy Practices – Treatment Facilities - NON-HCC, Hmong (PDF, 60 KB) PDF None Hmong
DDE-6003 F-26003AS Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC, Spanish (PDF, 81 KB) PDF None Spanish
DDE-6003 F-26003AS Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC, Spanish Word None Spanish
DDE-6003H F-26003H Letter - Notice of Privacy Practices – Treatment Facilities - HCC, Hmong (PDF, 90 KB) PDF None Hmong
DDE-6003S F-26003S Letter - Notice of Privacy Practices - Treatment Facilities - HCC, Spanish (PDF, 83 KB) PDF None Spanish
DDE-6003S F-26003S Letter - Notice of Privacy Practices - Treatment Facilities - HCC, Spanish Word None Spanish
DDE-6100 F-26100 Client Rights Limitation or Denial Documentation (PDF, 28 KB) PDF None English
DDE-6100 F-26100 Client Rights Limitation or Denial Documentation Word None English
DDE-6100A F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement (PDF, 11 KB) PDF None English
DDE-6100A F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement Word None English
DDE-6100S F-26100S Client Rights Limitation or Denial Documentation - Spanish (PDF, 31 KB) PDF None Spanish
DDE-6100S F-26100S Client Rights Limitation or Denial Documentation - Spanish Word None Spanish
DDE-9314 F-29314 COP Declaration of Income and Assets and State Residency (PDF, 52 KB) PDF None English
DDE-9315 F-29315 Instructions: Declaration of Income and Assets and State Residency (PDF, 50 KB) PDF None English
DDE-9316 F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant (PDF, 26 KB) PDF None English
DDE-9317 F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply (PDF, 32 KB) PDF None English
DDE-9318 F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP (PDF, 32 KB) PDF None English
DDE-9319 F-29319 COP Cost-Share Worksheet (PDF, 25 KB) PDF None English
DDE-9320 F-29320 COP Cost-Share Worksheet #1 Instructions (PDF, 27 KB) PDF None English
DDE-9321 F-29321 COP Cost-Share Worksheet #2 (PDF, 19 KB) PDF None English
DDE-9322 F-29322 COP Cost-Share Worksheet # 3 (PDF, 29 KB) PDF None English
DDE-9323 F-29323 Hardship Policy / Hidden Asset Policy (PDF, 19 KB) PDF None English
DDE-9324 F-29324 Uniform Cost Sharing Plan (PDF, 11 KB) PDF None English