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Forms: Numeric List 
F-00001 Through F-09999

This alphabetical 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
DPH F-00005 Senior FMNP Agency Application to Participate Word None English
DHCAA F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) PDF None English
DLTC F-00010 Risk Agreement - Participant Word None English
DQA F-00012 CBRF Completion Documents (PDF, 18 KB) PDF None English
DQA F-00014 Ceiling Closure Inspection Checklist (PDF, 22 KB) PDF None English
DQA F-00014 Ceiling Closure Inspection Checklist Word None English
DQA F-00015 Final Occupancy Inspection Checklist (PDF, 21 KB) PDF None English
DQA F-00015 Final Occupancy Inspection Checklist Word None English
DQA F-00016 Wall Closure Inspection Checklist (PDF, 17 KB) PDF None English
DQA F-00016 Wall Closure Inspection Checklist Word None English
DPH F-00017 Blood Lead Lab Reporting Word None English
DPH F-00018 Swimming Pool and Water Attraction Fecal Incident Report (PDF, 21 KB) PDF None English
DHCAA F-00020 Drug Addition Review Request (PDF, 653 KB) PDF None English
DHCAA F-00020 Drug Addition Review Request Word None English
DHCAA F-00021 HealthCheck Referral (PDF, 18 KB) PDF None English
DLTC F-00022 Nursing Home Rate Administrative Review Request (PDF, 12 KB) PDF None English
DLTC F-00022A Nursing Home Rate Administrative Review Request Completion Instructions (PDF, 17 KB) PDF None English
DHCAA F-00023 Case Management Agency Self-Audit Checklist (PDF, 191 KB) PDF None English
EXEC F-00024 HSRS Core Summary Report Excel None English
DQA F-00027 CSAS Standards Recertification Application - DHS 75.03 (PDF, 58 KB) PDF None English
DQA F-00027 CSAS Standards Recertification Application - DHS 75.03 Word None English
DHCAA F-00030 State Maximum Allowed Cost Drug Pricing Review Request (PDF, 1316 KB) PDF None English
DHCAA F-00030 State Maximum Allowed Cost Drug Pricing Review Request Word None English
DHCAA F-00030A State Maximum Allowed Cost Drug Pricing Review Request Completion Instructions (PDF, 35 KB) PDF None English
DPH F-00036 Power of Attorney for Finance and Property HTML 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
DQA F-00037D DQA E-Mail Subscription Service Sign-Up HTML None English
DLTC F-00037G ADRC Quality Improvement Listserv HTML None English
DMHSAS F-00037H Wisconsin Trauma-Informed Care (TIC) Listserve HTML None English
DPH F-00039 Asbestos Course Accreditation - Initial (PDF, 83 KB) PDF None English
DPH F-00040 Asbestos Course Accreditation - Renewal (PDF, 27 KB) PDF None English
DPH F-00041 Asbestos Project Notification (PDF, 145 KB) PDF None English
DPH F-00041 Asbestos Project Notification Word None English
DES F-00042 Knowledge Journal Word None English
DLTC F-00043 Communication to Local Educational Agency Regarding Child Referral Word None English
DES F-00044 User Agreement for System Access Word None English
DLTC F-00046 Family Care Program Enrollment Instructions and Important Information Word None English
DPH F-00047 Designated Asbestos Coordinator (PDF, 39 KB) PDF None English
DPH F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) (PDF, 34 KB) PDF None English
DPH F-00048H Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) - Hmong (PDF, 29 KB) PDF None Hmong
DPH F-00048S Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) - Spanish (PDF, 130 KB) PDF None Spanish
DPH F-00049 Asbestos Principal Instructor (PDF, 30 KB) PDF None English
DLTC F-00050 Oral Health Preliminary Exam and Prevention Services (PDF, 43 KB) PDF None English
DPH F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) (PDF, 77 KB) PDF None English
DPH F-00051H Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) - Hmong (PDF, 74 KB) PDF None Hmong
DPH F-00051S Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) - Spanish (PDF, 162 KB) PDF None Spanish
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
DQA F-00059 Outpatient Mental Health Clinic Application - DHS 35 (PDF, 87 KB) PDF None English
DQA F-00059 Outpatient Mental Health Clinic Application - DHS 35 Word None English
DPH F-00060 Declaration to Physicians (Living Will) (PDF, 27 KB) HTML Program English
DPH F-00060A Declaration To Physicians (Living Will) - Letter PDF Program 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
DHCAA F-00079 Prior Authorization / Drug Attachment for Modafinil and Nuvigil (PDF, 2902 KB) PDF None English
DHCAA F-00079 Prior Authorization / Drug Attachment for Modafinil and Nuvigil Word None English
DHCAA F-00079A Prior Authorization / Drug Attachment for Modafinil and Nuvigil Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-00080 Prior Authorization / Preferred Drug List (PA/PDL) for Symlin (PDF, 51 KB) PDF None English
DHCAA F-00080 Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Word None English
DHCAA F-00080A Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Completion Instructions (PDF, 48 KB) PDF None English
DHCAA F-00081 Prior Authorization / Drug Attachment for Suboxone and Buprenorphine (PDF, 1376 KB) PDF None English
DHCAA F-00081 Prior Authorization / Drug Attachment for Suboxone and Buprenorphine Word None English
DHCAA F-00081A Prior Authorization / Drug Attachment for Suboxone and Buprenorphine Completion Instructions (PDF, 34 KB) PDF None English
DPH F-00085 Power of Attorney for Health Care (PDF, 194 KB) HTML Program English
DPH F-00085A Power of Attorney for Health Care - Letter PDF Program English
DPH F-00086 Authorization for Final Disposition (PDF, 30 KB) HTML None English
DHCAA F-00098 Summary of Information Letter (PDF, 224 KB) PDF None English
DHCAA F-00100 State Vital Records Cover Letter Word None English
DHCAA F-00101 Authorization to Request Birth Records 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
DHCAA F-00107 Self-Employment Income Report (PDF, 91 KB) PDF None English
DHCAA F-00107H Self-Employment Income Report - Hmong (PDF, 51 KB) PDF None Hmong
DHCAA F-00107S Self-Employment Income Report - Spanish (PDF, 52 KB) PDF None Spanish
DHCAA F-00107W Self-Employment Income Report (Worksheet) (PDF, 37 KB) PDF None English
DLTC F-00113 Four Conditions for the Use of Funding in a CBRF Word None English
DPH F-00114 Service Director License Proxy for Individuals (PDF, 120 KB) PDF None English
DPH F-00114 Service Director License Proxy for Individuals Word None English
DMHSAS F-00115 Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument Word None English
DMHSAS F-00115S Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument - Spanish Word None Spanish
DQA F-00119 Personal Care Agency Application for Approval (PDF, 9 KB) PDF None English
DPH F-00123 Wisconsin Declaration of Domestic Partnership Application (PDF, 102 KB) PDF None English
DPH F-00123S Wisconsin Declaration of Domestic Partnership Application - Spanish (PDF, 65 KB) PDF None Spanish
DPH F-00124 Wisconsin Termination Domestic Partnership Certificate Application (PDF, 50 KB) PDF None English
DPH F-00124S Wisconsin Termination Domestic Partnership Certificate Application - Spanish (PDF, 77 KB) PDF None Spanish
DPH F-00126 Fax Application Declaration Wisconsin Domestic Partnership (PDF, 84 KB) PDF None English
DPH F-00126S Fax Application Declaration Wisconsin Domestic Partnership - Spanish (PDF, 63 KB) PDF None Spanish
DPH F-00127 Fax Application Declaration Wisconsin Domestic Partnership (PDF, 63 KB) PDF None English
DPH F-00127S Fax Application Declaration Wisconsin Domestic Partnership - Spanish (PDF, 123 KB) PDF None Spanish
DHCAA F-00136 FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) PDF None English
DHCAA F-00136H FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 42 KB) PDF None Hmong
DHCAA F-00136S FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 41 KB) PDF None Spanish
DQA F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency (PDF, 9 KB) PDF None English
DHCAA F-00142 Prior Authorization / Drug Attachment for Synagis (PDF, 2939 KB) PDF None English
DHCAA F-00142 Prior Authorization / Drug Attachment for Synagis Word None English
DHCAA F-00142A Prior Authorization / Drug Attachment for Synagis Completion Instructions (PDF, 49 KB) PDF 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
DMHSAS F-00153 Commitment to Offer Community Recovery Services (CRS) Word None English
DHCAA F-00154 Wisconsin Consultative Examination Inquiry Word None English
DQA F-00157 Assisted Living Administrator Training Course - Trainer Approval Application (PDF, 60 KB) PDF None English
DQA F-00157 Assisted Living Administrator Training Course - Trainer Approval Application Word None English
DQA F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum (PDF, 19 KB) PDF None English
DQA F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum Word None English
DQA F-00161 Caregiver Misconduct Reporting Requirements Worksheet (PDF, 68 KB) PDF None English
DQA F-00161 Caregiver Misconduct Reporting Requirements Worksheet Word None English
DQA F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries (PDF, 19 KB) PDF None English
DHCAA F-00162 Prior Authorization / Drug Attachment for Lipotropics, Omega-3 Acids (PDF, 1315 KB) PDF None English
DHCAA F-00162 Prior Authorization / Drug Attachment for Lovaza Word None English
DHCAA F-00162A Prior Authorization / Drug Attachment for Lovaza Completion Instructions (PDF, 61 KB) PDF None English
DHCAA F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs (PDF, 1382 KB) PDF None English
DHCAA F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs Word None English
DHCAA F-00163A Prior Authorization / Drug Attachment for Anti-Obesity Drugs Completion Instructions (PDF, 65 KB) PDF None English
DES F-00164 Civil Rights Compliance Plan Word None English
DES F-00165 Civil Rights Compliance Letter of Assurance Word None English
DES F-00166 Service Delivery / Employment Discrimination Complaint Word None English
DES F-00166AL Service Delivery / Employment Discrimination Complaint - Albanian (PDF, 51 KB) PDF None Albanian
DES F-00166AR Service Delivery / Employment Discrimination Complaint - Arabic (PDF, 111 KB) PDF None Arabic
DES F-00166BU Service Delivery / Employment Discrimination Complaint - Burmese (PDF, 108 KB) PDF None Burmese
DES F-00166CC Service Delivery / Employment Discrimination Complaint - Cantonese (PDF, 250 KB) PDF None Cantonese
DES F-00166CM Service Delivery / Employment Discrimination Complaint - Madarin (PDF, 335 KB) PDF None Mandarin
DES F-00166FA Service Delivery / Employment Discrimination Complaint - Farsi (PDF, 105 KB) PDF None Farsi
DES F-00166H Service Delivery / Employment Discrimination Complaint - Hmong (PDF, 59 KB) PDF None Hmong
DES F-00166KH Service Delivery / Employment Discrimination Complaint - Khmer (PDF, 114 KB) PDF None Khmer
DES F-00166KR Service Delivery / Employment Discrimination Complaint - Korean (PDF, 239 KB) PDF None Korean
DES F-00166L Service Delivery / Employment Discrimination Complaint - Laotian (PDF, 268 KB) PDF None Laotian
DES F-00166R Service Delivery / Employment Discrimination Complaint - Russian (PDF, 119 KB) PDF None Russian
DES F-00166S Service Delivery / Employment Discrimination Complaint - Spanish (PDF, 52 KB) PDF None Spanish
DES F-00166SE Service Delivery / Employment Discrimination Complaint - Serbian (PDF, 102 KB) PDF None Serbian
DES F-00166SO Service Delivery / Employment Discrimination Complaint - Somali (PDF, 51 KB) PDF None Somali
DES F-00166V Service Delivery / Employment Discrimination Complaint - Vietnamese (PDF, 121 KB) PDF None Vietnamese
DES F-00167 Civil Rights Complaint Consent/Release Word None English
DES F-00167AL Civil Rights Complaint Consent/Release - Albanian (PDF, 19 KB) PDF None Albanian
DES F-00167AR Civil Rights Complaint Consent/Release - Arabic (PDF, 87 KB) PDF None Arabic
DES F-00167BU Civil Rights Complaint Consent/Release - Burmese (PDF, 69 KB) PDF None Burmese
DES F-00167CC Civil Rights Complaint Consent/Release - Cantonese (PDF, 197 KB) PDF None Cantonese
DES F-00167CM Civil Rights Complaint Consent/Release - Mandarin (PDF, 239 KB) PDF None Mandarin
DES F-00167FA Civil Rights Complaint Consent/Release - Farsi (PDF, 59 KB) PDF None Farsi
DES F-00167H Civil Rights Complaint Consent/Release - Hmong (PDF, 20 KB) PDF None Hmong
DES F-00167KH Civil Rights Complaint Consent/Release - Khmer (PDF, 51 KB) PDF None Khmer
DES F-00167KR Civil Rights Complaint Consent/Release - Korean (PDF, 132 KB) PDF None Korean
DES F-00167L Civil Rights Complaint Consent/Release - Laotian (PDF, 173 KB) PDF None Laotian
DES F-00167R Civil Rights Complaint Consent/Release - Russian (PDF, 63 KB) PDF None Russian
DES F-00167S Civil Rights Complaint Consent/Release - Spanish (PDF, 20 KB) PDF None Spanish
DES F-00167SE Civil Rights Complaint Consent/Release - Serbian (PDF, 60 KB) PDF None Serbian
DES F-00167SO Civil Rights Complaint Consent/Release - Somali (PDF, 20 KB) PDF None Somali
DES F-00167V Civil Rights Complaint Consent/Release - Vietnamese (PDF, 94 KB) PDF None Vietnamese
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
DPH F-00171 Lead-Based Paint Activities & Investigations Certification Application - Company (PDF, 25 KB) PDF None English
DQA F-00176 Project Proposal (PDF, 36 KB) PDF None English
DQA F-00176 Project Proposal Word None English
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
DQA F-00191 Certified Outpatient Clinic Request for a Branch Office (PDF, 31 KB) PDF None English
DQA F-00191 Certified Outpatient Clinic Request for a Branch Office Word None English
DQA F-00191A Certified Outpatient Clinic Request for a School Branch Office (PDF, 31 KB) PDF None English
DQA F-00191A Certified Outpatient Clinic Request for a School Branch Office (PDF, 31 KB) Word None English
DHCAA F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids (PDF, 1324 KB) PDF None English
DHCAA F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids Word None English
DHCAA F-00194A Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids Completion Instructions (PDF, 42 KB) PDF None English
DLTC F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program Word None English
DPH F-00201 Occupant Protection Plan (Checklist for Lead-Based Paint Activities) (PDF, 34 KB) PDF None English
DMHSAS F-00202 Individual Service Plan - Community Recovery Services (CRS) Word None English
DMHSAS F-00202A Individual Service Plan - Individual Outcomes, Community Recovery Services (CRS) Word None English
DMHSAS F-00202i Individual Service Plan - Community Recovery Services (CRS) - Instructions Word None English
DMHSAS F-00203 County / Tribal Agency Application - Wisconsin Home and Community Based Services, Community Recovery Services (CRS) Word None English
DES F-00205 1 West Wilson Artwork Application, Insurance Value Declaration and Receipt Word None English
DES F-00205A 1 West Wilson Department Display Exhibit Application, Insurance Value Declaration and Receipt Word None English
OIG F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachnt (PDF, 74 KB) PDF None English
OIG F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment Word None English
OIG F-00212A Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment Completion Insttructions (PDF, 46 KB) PDF None English
DHCAA F-00219 Self-Employment Income Report - Farmer (PDF, 74 KB) PDF None English
DHCAA F-00219H Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) PDF None Hmong
DHCAA F-00219S Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) PDF None Spanish
DHCAA F-00219W Self-Employment Income Report - Farmer (Worksheet) (PDF, 37 KB) PDF 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
DMHSAS F-00230 Comprehensive Community Services Detailed Budget Plan Request Word None English
DLTC F-00232 Notice of Action - MCOs Word None English
DLTC F-00232H Notice of Action - MCOs - Hmong Word None Hmong
DLTC F-00232i Instructions for Using the Notice of Action (F-00232) (PDF, 177 KB) PDF None English
DLTC F-00232R Notice of Action - MCOs - Russian Word None Russian
DLTC F-00232S Notice of Action - MCOs - Spanish Word None Spanish
DHCAA F-00233 Renewal Summary Letter Word None English
DHCAA F-00233H Renewal Summary Letter (Hmong) Word None Hmong
DHCAA F-00233S Renewal Summary Letter (Spanish) Word None Spanish
DLTC F-00236 Request for a State Fair Hearing - MCO 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
DHCAA F-00238 Prior Authorization / Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents (PDF, 138 KB) PDF None English
DHCAA F-00238 Prior Authorization / Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents Word None English
DHCAA F-00238A Prior Authorization / Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents Completion Instructions (PDF, 88 KB) PDF None English
DHCAA F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips (PDF, 1400 KB) PDF None English
DHCAA F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips Word None English
DHCAA F-00239A Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips Completion Instructions (PDF, 43 KB) PDF None English
DHCAA F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) PDF None English
DHCAA F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use (PDF, 57 KB) PDF None English
DHCAA F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use Word None English
DMHSAS F-00251 Community Mental Health Services Block Grant - County Reporting Word None English
DES F-00255 Forms / Publications / Records Management Survey System None English
DMHSAS F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services (PDF, 77 KB) PDF None English
DMHSAS F-00260 Community Recovery Services - Service Plan Packet Quality Review Results Word None English
DQA F-00261 Personal Care Agency Personnel Record Review (PDF, 10 KB) PDF None English
DQA F-00261 Personal Care Agency Personnel Record Review Word None English
DQA F-00262 Personal Care Agency Application Materials Checklist (PDF, 18 KB) PDF None English
DQA F-00262 Personal Care Agency Application Materials Checklist Word None English
DQA F-00262a Personal Care Agency Application Regulatory Guidance Checklist (PDF, 245 KB) PDF None English
DQA F-00262a Personal Care Agency Application Regulatory Guidance Checklist Word None English
DQA F-00263 Personal Care Agency Record Review (PDF, 18 KB) PDF None English
DQA F-00263 Personal Care Agency Record Review Word None English
DQA F-00264 Personal Care Agency Surveyor Guide (PDF, 62 KB) PDF None English
DQA F-00264 Personal Care Agency Surveyor Guide 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
DQA F-00273 Behavioral Health Services Initial Certification Application - DHS 94 (PDF, 123 KB) PDF None English
DQA F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Word None English
DQA F-00276 Behavioral Health Services Renewal Certification Application - DHS 94 and 92 (PDF, 43 KB) PDF None English
DQA F-00276 Behavioral Health Services Renewal Certification Application - DHS 94 and 92 Word None English
DHCAA F-00280 Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents (PDF, 1396 KB) PDF None English
DHCAA F-00280 Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents Word None English
DHCAA F-00280A Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents Completion Instructions (PDF, 31 KB) PDF None English
DHCAA F-00281 Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents (PDF, 1315 KB) PDF None English
DHCAA F-00281 Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents Word None English
DHCAA F-00281A Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents Completion Instructions (PDF, 31 KB) PDF None English
DHCAA F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections (PDF, 1149 KB) PDF None English
DHCAA F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Word None English
DHCAA F-00286A Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Completion Instructions (PDF, 30 KB) PDF 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
DMHSAS F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application Word None English
DQA F-00302 CSAS Outpatient Clinic Recertification Application - DHS 75.13 (PDF, 51 KB) PDF None English
DQA F-00302 CSAS Outpatient Clinic Recertification Application - DHS 75.13 Word None English
DPH F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards (Access to Toilet Facilities in Retail Establishments) (PDF, 36 KB) PDF None English
DQA F-00309 Medicaid Provider Report (PDF, 65 KB) PDF None English
DQA F-00309 Medicaid Provider Report Word None English
DQA F-00311 Nursing Home MDS 3.0 Section Q Referral (PDF, 66 KB) PDF None English
DQA F-00311 Nursing Home MDS 3.0 Section Q Referral Word None English
DMHSAS F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Community Recovery Services Provider Entities Word None English
DMHSAS F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-specified Community Recovery Services Providers Word 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
DHCAA F-00330 Request for Replacement FoodShare Benefits (PDF, 28 KB) PDF None English
DHCAA F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) PDF 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
DMHSAS F-00335 Voluntary Agreement for Respite Care and Crisis Services Word None English
DPH F-00336 Tickborne Rickettsial Disease Case Report (PDF, 530 KB) PDF None English
DQA F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey (PDF, 26 KB) PDF None English
DQA F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey Word None English
OIG F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB) PDF None English
OIG F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) PDF None English
DHCAA F-00343 Eligibility Management (Income Maintenance) Policy Notification Sign-Up HTML None English
DHCAA F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services (PDF, 21 KB) PDF None English
DHCAA F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services Word None English
DPH F-00355 Healthiest Wisconsin 2020 Implementation Plan Endorsement Word None English
DHCAA F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application (PDF, 25 KB) PDF None English
DHCAA F-00363 FoodShare Renewal Request for a Closed Case Word None English
DHCAA F-00363H FoodShare Renewal Request for a Closed Case - Hmong Word None Hmong
DHCAA F-00363S FoodShare Renewal Request for a Closed Case - Spanish Word None Spanish
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
DPH F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB) PDF None English
DPH F-00375 Yellow Fever Uniform Stamp Application (PDF, 32 KB) PDF None English
DPH F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification (PDF, 17 KB) PDF None English
DQA F-00380 Outpatient Mental Health Clinic Certification Withdrawal (PDF, 29 KB) PDF None English
DQA F-00380 Outpatient Mental Health Clinic Certification Withdrawal Word None English
DQA F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist (PDF, 45 KB) PDF None English
DQA F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist Word None English
DQA F-00385 Nurse Aide Training - Student Waiver (PDF, 20 KB) PDF None English
DQA F-00385 Nurse Aide Training - Student Waiver Word None English
DQA F-00386 Request for Americans with Disability Act (ADA) Accommodation (PDF, 21 KB) PDF None English
DQA F-00386 Request for Americans with Disability Act (ADA) Accommodation Word 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 PDF None English
DLTC F-00389 Birth to 3 Program Provider Report of Revenue Word None English
DMHSAS F-00390 Incident Report - Community Recovery Services (CRS) Word None English
DMHSAS F-00390i Incident Report - Community Recovery Services (CRS), Instructions (PDF, 62 KB) PDF None English
DLTC F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan Word None English
DMHSAS F-00397 Consent of Disclosure of Information - Multiple Registration Central Registry Word None English
DHCAA F-00401 Expedited Emergency Supply Request (PDF, 35 KB) PDF None English
DHCAA F-00401 Expedited Emergency Supply Request Word None English
DHCAA F-00401A Expedited Emergency Supply Request Completion Instructions (PDF, 58 KB) PDF None English
DHCAA F-00407 Financial Records Request (PDF, 28 KB) PDF None English
DLTC F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information Word None English
DQA F-00417 AODA Prevention Services Recertification Application - DHS 75.04 (PDF, 52 KB) PDF None English
DQA F-00417 AODA Prevention Services Recertification Application - DHS 75.04 Word None English
DHCAA F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tablets (PDF, 132 KB) PDF None English
DHCAA F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tablets Word None English
DHCAA F-00433A Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tablets Completion Instructions (PDF, 33 KB) PDF None English
DQA F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) (PDF, 39 KB) PDF None English
DQA F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) Word None English
OQA F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 (PDF, 39 KB) PDF None English
OQA F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 Word None English
DPH F-00458 TDAP Cocooning Report (PDF, 17 KB) PDF None English
DQA F-00464 CSAS Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 (PDF, 52 KB) PDF None English
DQA F-00464 CSAS Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 Word None English
DQA F-00465 CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 (PDF, 56 KB) PDF None English
DQA F-00465 CSAS Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 Word None English
DQA F-00466 CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08 (PDF, 54 KB) PDF None English
DQA F-00466 CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08 Word None English
DQA F-00467 CSAS Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 (PDF, 59 KB) PDF None English
DQA F-00467 CSAS Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 Word None English
DQA F-00468 CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 (PDF, 61 KB) PDF None English
DQA F-00468 CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 Word None English
DQA F-00469 CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11 (PDF, 62 KB) PDF None English
DQA F-00469 CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11 Word None English
DQA F-00470 CSAS Day Treatment Service Recertification Application - DHS 75.12 (PDF, 55 KB) PDF None English
DQA F-00470 CSAS Day Treatment Service Recertification Application - DHS 75.12 Word None English
DQA F-00471 CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14 (PDF, 60 KB) PDF None English
DQA F-00471 CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14 Word None English
DQA F-00472 CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 (PDF, 64 KB) PDF None English
DQA F-00472 CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 Word None English
DQA F-00473 CSAS Intervention Service Recertification Application - DHS 75.16 (PDF, 63 KB) PDF None English
DQA F-00473 CSAS Intervention Service Recertification Application - DHS 75.16 Word None English
DQA F-00475 Comprehensive Community Services for Persons with Mental Disorders and Substance-Use Disorders Recertification Application Chapter DHS 36 (PDF, 49 KB) PDF None English
DQA F-00475 Comprehensive Community Services for Persons with Mental Disorders and Substance-Use Disorders Recertification Application Chapter DHS 36 Word None English
DHCAA F-00476 CARES Automated Systems Access Request Word None English
DHCAA F-00476A CARES Automated Systems Access Request Completion Instructions (PDF, 31 KB) PDF 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
DQA F-00482 CCS Initial Certification Application - DHS 36, F-00482 (PDF, 164 KB) PDF None English
DQA F-00482 CCS Initial Certification Application - DHS 36, F-00482 Word None English
DQA F-00496 Plan Review Code Interpretation Request (PDF, 26 KB) PDF None English
DQA F-00496 Plan Review Code Interpretation Request Word None English
DQA F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 (PDF, 46 KB) PDF None English
DQA F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 Word None English
DQA F-00513 CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 (PDF, 35 KB) PDF None English
DQA F-00513 CSAS Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 Word None English
DQA F-00514 CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 (PDF, 41 KB) PDF None English
DQA F-00514 CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 Word None English
DQA F-00515 CSAS Day Treatment Service Initial Certification Application - DHS 75.12 (PDF, 68 KB) PDF None English
DQA F-00515 CSAS Day Treatment Service Initial Certification Application - DHS 75.12 Word None English
DQA F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 (PDF, 37 KB) PDF None English
DQA F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 Word None English
DQA F-00517 CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 (PDF, 31 KB) PDF None English
DQA F-00517 CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 Word None English
DQA F-00518 CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 (PDF, 518 KB) PDF None English
DQA F-00518 CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 Word None English
DQA F-00519 CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 (PDF, 27 KB) PDF None English
DQA F-00519 CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 Word None English
DQA F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 (PDF, 25 KB) PDF None English
DQA F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 Word None English
DQA F-00521 CSAS Prevention Service Initial Certification Application - DHS 75.04 (PDF, 36 KB) PDF None English
DQA F-00521 CSAS Prevention Service Initial Certification Application - DHS 75.04 Word None English
DQA F-00523 Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03 (PDF, 126 KB) PDF None English
DQA F-00523 Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03 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
DQA F-00537 CSAS Intervention Services Initial Certification Application - DHS 75.16 (PDF, 43 KB) PDF None English
DQA F-00537 CSAS Intervention Services Initial Certification Application - DHS 75.16 Word None English
DQA F-00538 CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 (PDF, 104 KB) PDF None English
DQA F-00538 CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 Word None English
DLTC F-00539 Children's Long Term Support Service Coordination Rate Worksheet Excel None English
DLTC F-00539A Community Options Program 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
DQA F-00544 CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13 (PDF, 30 KB) PDF None English
DQA F-00544 CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13 Word None English
DQA F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 (PDF, 37 KB) PDF None English
DQA F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 Word None English
DQA F-00546 CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 (PDF, 54 KB) PDF None English
DQA F-00546 CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 Word None English
DQA F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 (PDF, 51 KB) PDF None English
DQA F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 Word None English
DQA F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 (PDF, 107 KB) PDF None English
DQA F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 Word None English
DQA F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 (PDF, 144 KB) PDF None English
DQA F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 Word None English
DPH F-00553 Professional & Occupational License Application & Affidavit (PDF, 62 KB) PDF None English
DPH F-00553 Professional & Occupational License Application & Affidavit Word None English
DHCAA F-00556 Prior Authorization - Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age or Younger (PDF, 2009 KB) PDF None English
DHCAA F-00556 Prior Authorization - Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age or Younger Word None English
DHCAA F-00556A Prior Authorization - Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age or Younger Completion Instructions (PDF, 88 KB) PDF None English
DLTC F-00558 Self-Assessment Summary Word None English
DLTC F-00565 Program in Partnership Plan - PIPP Word None English
DPH F-00567 Emergency Medical Services Complaint Word None English
DPH F-00568 EMS Board Sub-Committee Appointment Application Word None English
DPH F-00569 Request for Waiver of Administrative Rule for Licensure Word None English
DQA F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 (PDF, 51 KB) PDF None English
DQA F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 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
OIG F-00577 Report Fraud ASP None English
DLTC F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System Word None English
DHCAA F-00583 Prior Authorization - Drug Attachment for Hepatitis C Protease Inhibitors (PDF, 586 KB) PDF None English
DHCAA F-00583 Prior Authorization - Drug Attachment for Hepatitis C Protease Inhibitors Word None English
DHCAA F-00583A Prior Authorization - Drug Attachment for Hepatitis C Protease Inhibitors Completion Instructions (PDF, 39 KB) PDF None English
DMHSAS F-00588 PPS Alcohol and Other Drug Abuse Module Word None English
DMHSAS F-00588a PPS AODA Deskcard (PDF, 115 KB) PDF None English
DMHSAS F-00596 PPS Mental Health Module Word None English
DMHSAS F-00596a PPS Mental Health Deskcard (PDF, 96 KB) PDF None English
DPH F-00601 Algal Bloom Exposure Report System None English
DES F-00603 PPS (Program Participation System) Core Module Word None English
DES F-00603a PPS Core Deskcard (PDF, 20 KB) PDF None English
DLTC F-00603i Program Participation System Core Instructions (PDF, 67 KB) PDF None English
DPH F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application Word None English
DLTC F-00615 Change Project Report Word None English
DHCAA F-00622 Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents, Injectable (PDF, 2758 KB) PDF None English
DHCAA F-00622 Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents, Injectable Word None English
DHCAA F-00622A Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents, Injectable Completion Instructions (to be used 7/1/2012 and after) (PDF, 30 KB) PDF None English
DHCAA F-00628 Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) PDF None English
DHCAA F-00628 Consortium Response to the State IM Second Party Review Finding 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, 86 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, 87 KB) PDF None Spanish
DLTC F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records Word None English
DLTC F-00634i County Birth to 3 Program Annual Notification of Parental Rights Regarding Records-Instructions (PDF, 444 KB) PDF None English
DLTC F-00634iS County Birth to 3 Program Annual Notification of Parental Rights Regarding Records-Instructions, Spanish (PDF, 81 KB) PDF None Spanish
DLTC F-00634S County Birth to 3 Program Annual Notification of Parental Rights Regarding Records, Spanish Word None Spanish
DHCAA F-00639 Agency Data Security Staff User Agreement Word None English
DPH F-00646 Emergency Medical Service Training Center - Training Eligibility Certification Word None English
DPH F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR) Excel None English
DPH F-00653a Patient Data Import Training Excel None English
DPH F-00653b Surgeon Data Import Training Excel None English
DQA F-00657 Military Training Verification (PDF, 24 KB) PDF None English
DQA F-00657 Military Training Verification Word None English
DPH F-00658 Temporary Food Service Permit Application (PDF, 329 KB) PDF None English
DMHSAS F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval Word None English
DMHSAS F-00660A Client Rights Office Consult Question Word None English
DLTC F-00676 Youth Transition Pre-Test Word None English
DLTC F-00676A Youth Transition Post-Test Word None English
DLTC F-00681 Partnership - Three (3) Managed Care Organization (MCO) Options Word None English
DLTC F-00681A Family Care - Three (3) Managed Care Organization (MCO) Options Word None English
DLTC F-00681B Partnership - Two (2) Managed Care Organization (MCO) Options Word None English
DLTC F-00681C Family Care - Two (2) Managed Care Organization (MCO) Options Word None English
DHCAA F-00685 Statement of Tribal Affiliation (PDF, 24 KB) PDF None English
DLTC F-00688 Consent to Release Medical and Birth-3 Information/Referral to Birth-3 Word None English
DHCAA F-00694 Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis (PDF, 604 KB) PDF None English
DHCAA F-00694 Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis Word None English
DHCAA F-00694A Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis Completion Instructions (PDF, 60 KB) PDF None English
DLTC F-00695 Connections to Community Living Non-MDS Referral and Tracking Word None English
DHCAA F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) (PDF, 141 KB) PDF None English
DHCAA F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) Word None English
DHCAA F-00701A Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) Completion Instructions (PDF, 40 KB) PDF None English
DPH F-00703 Patient Side Training Report (PDF, 86 KB) PDF None English
DHCAA F-00704 Prior Authorization - Committee Public Testimony Registration (PDF, 29 KB) PDF None English
DES F-00724 Contract Performance - Payment Bond Form Word None English
DQA F-00728 Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix (PDF, 150 KB) PDF None English
DQA F-00728 Division of Quality Assurance Regulated Entity Automated Background Information Disclosure (BID) and Appendix Word None English
DQA F-00740 Quality Improvement Event Analysis Summary and Suggested Event Analysis Process (PDF, 46 KB) Restricted None English
DES F-00754 Wisconsin Civil Service Request for Examination Accommodations (PDF, 27 KB) PDF None English
DES F-00754 Wisconsin Civil Service Request for Examination Accommodations Word None English
DPH F-00757 Consent to Tattoo Procedure - Release and Waiver of All Claims (PDF, 121 KB) PDF None English
DPH F-00758 Consent to Pierce - Release and Waiver of All Claims (PDF, 119 KB) PDF None English
DPH F-00758A Consent to Pierce Minor - Release and Waiver of All Claims (PDF,126 KB) PDF None English
DES F-00759 Business Associate Agreement - With Contract Word None English
DLTC F-00777 MAPT Vendor Related Allocation Formula Word None English
DLTC F-00780 Options Counseling Tip Card Paper Program English
DQA F-00784 Personal Care Agency Client Rights (PDF, 19 KB) PDF None English
DQA F-00784 Personal Care Agency Client Rights Word None English
DQA F-00785 Outpatient Mental Health Clinic Recertification Application (PDF, 54 KB) PDF None English
DQA F-00785 Outpatient Mental Health Clinic Recertification Application Word None English
DHCAA F-00787 Prior Authorization - Exemption Request for CT and MR Imaging Services (PDF, 23 KB) PDF None English
DHCAA F-00787 Prior Authorization - Exemption Request for CT and MR Imaging Services Word None English
DHCAA F-00805 Prior Authorization - Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators (PDF, 49 KB) PDF None English
DHCAA F-00805 Prior Authorization - Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators Word None English
DHCAA F-00805A Prior Authorization - Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators Completion Instructions (PDF, 46 KB) PDF None English
DQA F-00812 Wisconsin Music and Memory Initiative Nursing Home Application Word None English
DHCAA F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy (PDF, 91 KB) PDF None English
DHCAA F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Word None English
DHCAA F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member (PDF, 1.3 MB) PDF None English
DHCAA F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member Word None English
DHCAA F-00842 Pharmacy Services Lock-In Program - Program Summary (PDF, 47 KB) PDF None English
DPH F-00851 AIDS/HIV Drug Assistance and Insurance Premium Subsidy Programs - Six Month Report (PDF, 105 KB) Word None English
DLTC F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report Word None English
DHCAA F-00855 Medication Therapy Management Case Management Software Requirements (PDF, 591 KB) PDF None English
DHCAA F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF, 47 KB) PDF None English
DMHSAS F-00880 Intent to Provide Comprehensive Community Services (CCS) on a Regional Basis Word None English
DHCAA F-00885 Specialized Medical Vehicle Insurance Documentation Checklist (PDF, 48 KB) PDF None English
DHCAA F-00885 Specialized Medical Vehicle Insurance Documentation Checklist 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
DQA F-00891 Abuse and Neglect Prevention Training - DVD Request (PDF, 20 KB) PDF None English
DPH F-00893 Affidavit of No Social Security Number - EMS Professional Licensing Word None English
DHCF F-00898 Explanation of Medicare Benefits for Diabetic Supply Claims (PDF, 1341 KB) PDF None English
DHCF F-00898 Explanation of Medicare Benefits for Diabetic Supply Claims Word None English
DHCF F-00898A Explanation of Medicare Benefits for Diabetic Supply Claims Completion Instructions (PDF, 35 KB) PDF None English
DQA F-00907 OASIS Assessment Deletion Request (PDF, 17 KB) PDF None English
DQA F-00907 OASIS Assessment Deletion Request Word None English
DMHSAS F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance Word None English
DQA F-00913 Annual Survey of Nursing Homes - 2013 Word None English
DHCAA F-00914 BadgerCare Plus Tax Filer Information (PDF, 238 KB) PDF None English
DHCAA F-00914A BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) PDF None English
DHCAA F-00914S BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) PDF None Spanish
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
DHCAA F-00916 ADAP WCDP and WWWP Provider File Update Request (1444 KB) PDF None English
DHCAA F-00916 ADAP WCDP and WWWP Provider File Update Request Word None English
DHCAA F-00916A ADAP WCDP and WWWP Provider File Update Request Completion Instructions (28 KB) PDF None English
DHCAA F-00917 Provider Enrollment Application Process System None English
DHCF F-00922 Behavioral Health Integrated Care Health Home Certification Application (PDF, 380 KB) PDF None English
DHCF F-00922 Behavioral Health Integrated Care Health Home Certification Application Word None English
  F-00923 Reschedule Lead (PB) Certification Exam (PDF, 90 KB) PDF 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
EXEC F-00943 Exhibit II - Tribal Work Plan Word None English
DMHSAS F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model Word None English
EXEC F-00945 Waiver Request 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
DHCAA F-00985 How the Affordable Care Act may affect SeniorCare members who get Prescriptions (PDF, 62 KB) PDF None English
  F-00985H How the Affordable Care Act may affect SeniorCare members who get Prescriptions (Hmong) (PDF, 72 KB) PDF None Hmong
  F-00985S How the Affordable Care Act may affect SeniorCare members who get Prescriptions (Spanish) (PDF, 71 KB) PDF None Spanish
DPH F-00986 Newborn Screening Program - Condition Nomination Word None English
DPH F-00987 EMS Service Operational Plan Advanced Skills Addendum – EMT-Basic Word None English
DPH F-00987A EMS Service Operational Plan Advanced Skills Addendum – Intermediate Word None English
DPH F-00987B EMS Service Operational Plan Advanced Skills Addendum – Advanced EMT Word None English
DPH F-00987C EMS Service Operational Plan Advanced Skills Addendum – First Responder Word None English
DPH F-00987D EMS Service Operational Plan Advanced Skills Addendum – Paramedic Word None English
DPH F-00987E EMS Service Operational Plan Advanced Skills Addendum – Critical Care Word None English
DLTC F-00989 Individualized Family Service Plan (IFSP) Word None English
DLTC F-00989A Child and Family Information (IFSP) Word None English
DLTC F-00989AP Individualized Family Service Plan (IFSP)-Full Edition Word None English
DLTC F-00989B Summary of Development (IFSP) Word None English
DLTC F-00989C Summary of Development - Child’s Positive Social Emotional Skills (IFSP) Word None English
DLTC F-00989D Summary of Development - Child’s Use of Knowledge and Skills (IFSP) Word None English
DLTC F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) Word None English
DLTC F-00989F Early Intervention Team Report/Wisconsin Early Intervention Eligibility Determination (IFSP) Word None English
DLTC F-00989G Tell Us About Your Family (IFSP) Word None English
DLTC F-00989H Child/Family Outcome (IFSP) Word None English
DLTC F-00989i Instructions for Completing Wisconsin’s Individualized Family Service Plan (IFSP) (PDF, 262 KB) PDF None English
DLTC F-00989J Transition Plan—Turning 3 Years Old (IFSP) Word None English
DLTC F-00989K Transition Plan—Other (IFSP) Word None English
DLTC F-00989L Summary of Services (IFSP) Word None English
DLTC F-00989M Justification for Services Provided In Locations Other than Natural Environments (IFSP) Word None English
DLTC F-00989N Other Services / Community and Medical Supports (IFSP) Word None English
DLTC F-00989P Individualized Family Service Plan Team Signature (IFSP) Word None English
HCF-01002 F-01002 HealthCheck Individual Health History (PDF, 797 KB) PDF None English
HCF-01002 F-01002 HealthCheck Individual Health History Word None English
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong (PDF, 861 KB) PDF None Hmong
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong Word None Hmong
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish (PDF, 434 KB) PDF None Spanish
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish Word None Spanish
HCF-01003 F-01003 Wisconsin Medicaid - Certification of Public Expenditures (PDF, 279 KB) PDF None English
HCF-01008 F-01008 Wisconsin Medicaid - Notification of Hospice Benefit Election (PDF, 91 KB) PDF None English
HCF-01008 F-01008 Wisconsin Medicaid - Notification of Hospice Benefit Election Word None English
HCF-01009 F-01009A Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under (PDF, 23 KB) PDF None English
HCF-01009 F-01009A Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under Word None English
HCF-01009H F-01009AH Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Hmong (PDF, 25 KB) PDF None Hmong
HCF-01009H F-01009AH Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Hmong Word None Hmong
HCF-01009S F-01009AS Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Spanish (PDF, 25 KB) PDF None Spanish
HCF-01009S F-01009AS Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Spanish Word None Spanish
HCF-01009B F-01009B Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older (PDF, 22 KB) PDF None English
HCF-01009B F-01009B Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older Word None English
HCF-01009BH F-01009BH Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Hmong (PDF, 24 KB) PDF None Hmong
HCF-01009BH F-01009BH Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Hmong Word None Hmong
HCF-01009BS F-01009BS Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Spanish (PDF, 25 KB) PDF None Spanish
HCF-01009BS F-01009BS Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Spanish Word None Spanish
HCF-01010 F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge (PDF, 87 KB) PDF None English
HCF-01010 F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge Word None English
HCF-01011 F-01011 Wisconsin Medicaid - Physician Certification / Recertification of Terminal Illness (PDF, 92 KB) PDF None English
HCF-01011 F-01011 Wisconsin Medicaid - Physician Certification / Recertification of Terminal Illness Word None English
HCF-01012 F-01012 Reimbursement Request for a PASARR Level I Screen (PDF, 45 KB) PDF None English
HCF-01012 F-01012 Reimbursement Request for a PASARR Level I Screen Word None English
HCF-01012A F-01012A Reimbursement Request for a PASARR Level I Screen Instructions (PDF, 30 KB) PDF None English
HCF-01013 F-01013 Nurses Aide Training and Competency Test Reimbursement Request (PDF, 52 KB) PDF None English
HCF-01013 F-01013 Nurse Aide Training and Competency Test Reimbursement Request Word None English
HCF-01013A F-01013A Nurses Aide Training and Competency Test Reimbursement Request Instructions (PDF, 31 KB) PDF None English
HCF-01016 F-01016 Provider Suggestion (PDF, 12 KB) PDF None English
HCF-01017 F-01017 Wisconsin Medicaid - Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement (PDF, 37 KB) PDF None English
HCF-01017 F-01017 Wisconsin Medicaid - Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Word None English
HCF-01017A F-01017A Wisconsin Medicaid - Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Completion Instructions (PDF, 35 KB) PDF None English
HCF-01018 F-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers (PDF, 235 KB) PDF None English
HCF-01018 F-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers Word None English
HCF-01020 F-01020 Wisconsin Medicaid Request for Nursing Home Care Determination (PDF, 27 KB) PDF None English
HCF-01020 F-01020 Wisconsin Medicaid Request for Nursing Home Care Determination Word None English
HCF-01020A F-01020A 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-01050 F-01050 Wisconsin Medicaid - Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification (PDF, 67 KB) PDF None English
HCF-01050A F-01050A Wisconsin Medicaid - Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions (PDF, 332 KB) PDF None English
HCF-01058 F-01058 Wisconsin Chronic Renal Disease Program - Drug Benefits Important Notice (PDF, 40 KB) PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review (PDF, 129 KB) PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review Word None English
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish (PDF, 131 KB) PDF None Spanish
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish Word None Spanish
HCF-01063 F-01063 HealthCheck Family History (PDF, 392 KB) PDF None English
HCF-01063 F-01063 HealthCheck Family History Word None English
HCF-01063S F-01063S HealthCheck Family History - Spanish (PDF, 391 KB) PDF None Spanish
HCF-01063S F-01063S HealthCheck Family History - Spanish Word None Spanish
HCF-01066 F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (PDF, 13 KB) PDF None English
HCF-01066 F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) Word None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF, 72 KB) PDF None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF, 13 KB) Word None English
HCF-01066AS F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age - Spanish (PDF, 62 KB) PDF None Spanish
HCF-01066AS F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age - Spanish Word None Spanish
HCF-01066B F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (PDF, 12 KB) PDF None English
HCF-01066B F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (PDF, 12 KB) Word None English
HCF-01066BS F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age) - Spanish (PDF, 77 KB) PDF None Spanish
HCF-01066BS F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age) - Spanish (PDF, 14 KB) Word None Spanish
HCF-01066S F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age) - Spanish (PDF, 40 KB) PDF None Spanish
HCF-01066S F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age) - Spanish Word None Spanish
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing (PDF, 280 KB) PDF None English
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing Word None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit (PDF, 195 KB) PDF None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit Word None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 to 8 Week Visit (PDF, 137 KB) PDF None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 to 8 Week Visit Word None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit (PDF, 152 KB) PDF None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit Word None English
HCF-01068D F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit (PDF, 193 KB) PDF None English
HCF-01068C F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit Word None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit (PDF, 152 KB) PDF None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit Word None English
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit (PDF, 169 KB) PDF None English
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit Word None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit (PDF, 160 KB) PDF None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit Word None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit (PDF, 172 KB) PDF None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit Word None English
HCF-01068I F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit (PDF, 236 KB) PDF None English
HCF-01068I F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit Word None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit (PDF, 160 KB) PDF None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit Word None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit (PDF, 149KB) PDF None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit Word None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit (PDF, 134 KB) PDF None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit Word None English
HCF-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey (PDF, 189 KB) PDF None English
HCF-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey Word None English
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish (PDF, 134 KB) PDF None Spanish
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish Word None Spanish
HCF-01070 F-01070 Ambulance Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01072 F-01072 Ambulatory Surgical Center Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01074 F-01074 Anesthetist Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01082 F-01082 Audiology Terms of Reimbursement (PDF, 53 KB) PDF None English
HCF-01083 F-01083 Hearing Instrument Specialist Terms of Reimbursement (PDF, 52 KB) PDF None English
HCF-01084 F-01084 Speech - Language Pathology Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01086 F-01086 Case Management Terms of Reimbursement (PDF, 43 KB) PDF None English
HCF-01088 F-01088 Chiropractor Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01092 F-01092 Dental - Dental Hygienists Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01094 F-01094 Free Standing End-Stage Renal Disease Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01095 F-01095 Hospital Affiliated End-Stage Renal Disease Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01099 F-01099 Family Planning Clinic Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01104 F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster Excel None English
HCF-01105 F-01105 Pre-Natal Care Coordination Pregnancy Questionnaire (PDF, 211 KB) PDF None English
HCF-01105A F-01105A Pre-Natal Care Coordination Pregnancy Questionnaire Completion Instructions (PDF, 67 KB) PDF None English
HCF-01105H F-01105H Pre-Natal Care Coordination Pregnancy Questionnaire - Hmong (PDF, 197 KB) PDF None Hmong
HCF-01105S F-01105S Pre-Natal Care Coordination Program Pregnancy Questionnaire - Spanish (PDF, 202 KB) PDF None Spanish
HCF-01108 F-01108 Federally Qualified Health Center Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01112 F-01112 HealthCheck Verification Card Paper Form Center English
HCF-01113 F-01113 HealthCheck Other Services Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01114 F-01114 HealthCheck Screener and Case Management Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01118 F-01118 Child Care Coordination Family Questionnaire (PDF, 414 KB) PDF None English
HCF-01118A F-01118A Child Care Coordination Family Questionnaire Completion Instructions(PDF,52 KB) PDF None English
HCF-01121 F-01121 Home Health Agency Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01125 F-01125 Hospice Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01127 F-01127 Border Status Hospitals Terms of Reimbursement (PDF, 38 KB) PDF None English
HCF-01128 F-01128 Hospital Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01130 F-01130 Laboratories Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01131 F-01131 Blood Banks Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01134 F-01134 Wisconsin Medicaid - Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit (PDF, 77 KB) PDF None English
HCF-01134 F-01134 Wisconsin Medicaid - Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit Word None English
HCF-01143 F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification (PDF, 32 KB) PDF None English
HCF-01144 F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification (PDF, 30 KB) PDF None English
HCF-01145 F-01145 Wisconsin Hemophilia Home Care Program Residency Verification (PDF, 20 KB) PDF None English
HCF-01146 F-01146 Wisconsin Chronic Disease Program Provider Data Sheet (PDF, 45 KB) PDF 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
HCF-01149 F-01149 Wisconsin Medicaid - Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements (PDF, 45 KB) PDF None English
HCF-01149 F-01149 Wisconsin Medicaid - Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements Word None English
HCF-01153 F-01153 Breast Pump Order (PDF, 26 KB) PDF None English
HCF-01159 F-01159 Other Coverage Discrepancy Report (PDF, 73 KB) PDF None English
HCF-01159 F-01159 Other Coverage Discrepancy Report Word None English
HCF-01160 F-01160 Acknowledgement of Receipt of Hysterectomy Information (PDF, 131 KB) PDF None English
HCF-01160 F-01160 Acknowledgement of Receipt of Hysterectomy Information Word None English
DHCAA F-01160A Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-01160AH Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (Hmong) (PDF, 23 KB) PDF None English
DHCAA F-01160AS Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-01160H Acknowledgement of Receipt of Hysterectomy Information - Hmong (PDF, 57 KB) PDF None Hmong
DHCAA F-01160H Acknowledgement of Receipt of Hysterectomy Information - Hmong Word None Hmong
DHCAA F-01160S Acknowledgement of Receipt of Hysterectomy Information - Spanish (PDF, 42 KB) PDF None Spanish
DHCAA F-01160S Acknowledgement of Receipt of Hysterectomy Information - Spanish Word None Spanish
HCF-01161 F-01161 Abortion Certification Statements (PDF, 94 KB) PDF None English
HCF-01161 F-01161 Abortion Certification Statements Word None English
HCF-01162 F-01162 Certification of Emergency for Non-U.S. Citizens (PDF, 12 KB) PDF None English
HCF-01162A F-01162A Certification of Emergency for Non-U.S. Citizens (PDF, 21 KB) PDF None English
HCF-01164 F-01164 Consent for Sterilization (PDF, 123 KB) PDF None English
HCF-01164 F-01164 Consent for Sterilization Word None English
HCF-01164A F-01164A Consent for Sterilization Instructions (PDF, 119 KB) PDF None English
HCF-01164S F-01164S Consent for Sterilization - Spanish (PDF, 23 KB) PDF None Spanish
HCF-01164S F-01164S Consent for Sterilization - Spanish (PDF, 23 KB) Word None Spanish
HCF-01165 F-01165 Newborn Report (PDF, 50 KB) PDF None English
HCF-01165 F-01165 Newborn Report Word None English
HCF-01168 F-01168 Wisconsin Medicaid - Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases (PDF, 40 KB) PDF None English
HCF-01168 F-01168 Wisconsin Medicaid - Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases Word None English
HCF-01170 F-01170 Written Correspondence Inquiry (PDF, 57 KB) PDF None English
HCF-01170 F-01170 Written Correspondence Inquiry Word None English
HCF-01176 F-01176 Prior Authorization Fax Cover Sheet (PDF, 16 KB) PDF None English
HCF-01176 F-01176 Prior Authorization Fax Cover Sheet Word None English
HCF-01182 F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers (PDF, 48 KB) PDF None English
HCF-01182 F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers Word None English
HCF-01184 F-01184 Wisconsin Hemophilia Home Care Program Application (PDF, 49 KB) PDF None English
HCF-01184A F-01184A Wisconsin Hemophilia Home Care Program Application Instructions (PDF, 38 KB) PDF None English
HCF-01185 F-01185 Wisconsin Adult Cystic Fibrosis Program Application (PDF, 84 KB) PDF None English
HCF-01185A F-01185A Wisconsin Adult Cystic Fibrosis Program Application Instructions (PDF, 39 KB) PDF None English
HCF-01186 F-01186 Wisconsin Chronic Renal Disease Program Application (PDF, 55 KB) PDF None English
HCF-01186A F-01186A Wisconsin Chronic Renal Disease Program Application Instructions (PDF, 39 KB) PDF None English
HCF-01187 F-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement (PDF, 46 KB) PDF None English
HCF-01187A F-01187A Wisconsin Hemophilia Home Care Program Financial Need Statement Instructions (PDF, 39 KB) PDF None English
HCF-01188 F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement (PDF, 46 KB) PDF None English
HCF-01188A F-01188A Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Instructions (PDF, 39 KB) PDF None English
HCF-01189 F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement (PDF, 50 KB) PDF None English
HCF-01189A F-01189A Wisconsin Chronic Renal Disease Program Financial Need Statement Instructions (PDF, 40 KB) PDF None English
HCF-01194 F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01195 F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01196 F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01197 F-01197 Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation (PDF, 23 KB) PDF None English
HCF-01197 F-01197 Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation Word None English
HCF-01197A F-01197A Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation Completion Instructions (PDF, 15 KB) PDF None English
HCF-01198 F-01198 Wisconsin Medicaid - Optional School-Based Services Activity Log Nursing / Therapy Medical Services (PDF, 122 KB) PDF None English
HCF-01198 F-01198 Wisconsin Medicaid - Optional School-Based Services Activity Log Nursing / Therapy Medical Services Word None English
HCF-01199 F-01199 Wisconsin Medicaid - Optional School-Based Services Activity Medication Administration (PDF, 113 KB) PDF None English
HCF-01199 F-01199 Wisconsin Medicaid - Optional School-Based Services Activity Medication Administration Word None English
DLTC F-01200 IRIS Program Cost Share Repayment Agreement Word None English
DLTC F-01201 IRIS Provider Education—Hired Worker Employee Set-Up Word None English
DLTC F-01201A IRIS Participant-Hired Worker Relationship Identification Word None English
DLTC F-01201B IRIS Supportive Home Care/Self-Directed Personal Care/Respite Care Training Verification Word None English
DLTC F-01201C IRIS Employer/Employee Agreement Word None English
DLTC F-01202 Participant IRIS Consultant Agency (ICA) Selection Word None English
DLTC F-01202A Participant IRIS Consultant Agency (ICA) Selection - Change Word None English
DLTC F-01203 IRIS Provider Education—Health and Safety – Incident Reporting Word None English
DLTC F-01204 IRIS Program Notice of Action Word None English
DLTC F-01204A Letter - IRIS Program Notice of Action--Denial Word None English
DLTC F-01204B Letter - IRIS Program Notice of Action--Limit Word None English
DLTC F-01204C Letter - IRIS Program Notice of Action--Reduction Word None English
DLTC F-01204D Letter - IRIS Program Notice of Action--Termination Word None English
DLTC F-01204E Letter - IRIS Program Notice of Action--Functional Eligibility 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-01205AH IRIS Participant Education--Health and Safety - Incident Reporting, Hmong Word None Hmong
DLTC F-01205AR IRIS Participant Education--Health and Safety - Incident Reporting, Russian Word None Russian
DLTC F-01205AS IRIS Participant Education--Health and Safety - Incident Reporting, Spanish Word None Spanish
DLTC F-01205B IRIS Participant Education--Budget Amendment Process Word None English
DLTC F-01205BH IRIS Participant Education--Budget Amendment Process, Hmong Word None Hmong
DLTC F-01205BR IRIS Participant Education--Budget Amendment Process, Russian Word None Russian
DLTC F-01205BS IRIS Participant Education--Budget Amendment Process, Spanish Word None Spanish
DLTC F-01205C IRIS Participant Education--One-Time Expense Process Word None English
DLTC F-01205CH IRIS Participant Education--One-Time Expense Process, Hmong Word None Hmong
DLTC F-01205CR IRIS Participant Education--One-Time Expense Process, Russian Word None Russian
DLTC F-01205CS IRIS Participant Education--One-Time Expense Process, Spanish Word None Spanish
DLTC F-01205D IRIS Participant Education - Program Integrity - Program Integrity Word None English
DLTC F-01205E IRIS Participant Education - Program Integrity - Budget Monitoring Word None English
DLTC F-01205F IRIS Participant Education – Complaints and Grievances Word None English
DLTC F-01205FH IRIS Participant Education – Complaints and Grievances, Hmong Word None Hmong
DLTC F-01205FR IRIS Participant Education – Complaints and Grievances, Russian Word None Russian
DLTC F-01205FS IRIS Participant Education – Complaints and Grievances, Spanish Word None Spanish
DLTC F-01205G IRIS Participant Education – Notice of Action and Appeals Word None English
DLTC F-01205GH IRIS Participant Education – Notice of Action and Appeals, Hmong Word None Hmong
DLTC F-01205GR IRIS Participant Education – Notice of Action and Appeals, Russian Word None Russian
DLTC F-01205GS IRIS Participant Education – Notice of Action and Appeals, Spanish Word None Spanish
DLTC F-01205H IRIS Participant Education—Self-Direction Responsibilities, Hmong Word None Hmong
DLTC F-01205i Participant Education - Program Integrity - Conflict of Interest Word None English
DLTC F-01205R IRIS Participant Education—Self-Direction Responsibilities, Russian Word None Russian
DLTC F-01205S IRIS Participant Education—Self-Direction Responsibilities, Spanish Word None Spanish
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-01206B IRIS One-Time Expense Request - Ramp Word None English
DLTC F-01207 IRIS Fiscal Employer Agent Quality Management Plan Word None English
DLTC F-01207A IRIS Fiscal/Employer Agent Quality Management Plan Tracking Excel None English
DLTC F-01208 IRIS Consultant Agency Quality Management Plan Word None English
DLTC F-01208A IRIS Consultant Agency Quality Management Plan Tracking 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
DLTC F-01212 Grievance Form--IRIS Program Word None English
DLTC F-01213 Accessibility Assessment Request Word None English
DPH F-01215 National CLAS Standards Pledge Word None English
DQA F-01216 CCS for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application (PDF, 315 KB) PDF None English
DQA F-01216 CCS for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application Word None English
DLTC F-01217A IRIS Advisory Committee Application Word None English
DPH F-01218 WISEWOMAN Client Consent Word Program English
DPH F-01218S WISEWOMAN Client Consent - Spanish Word Program Spanish
DPH F-01219 WISEWOMAN Health History Assessment Word Program English
DPH F-01219-pckt WISEWOMAN Assessment Packet Word Program English
DPH F-01219S WISEWOMAN Health History Assessment - Spanish Word Program Spanish
DPH F-01219S-pckt WISEWOMAN Assessment Packet - Spanish Word Program Spanish
DPH F-01220 WISEWOMAN Healthy Lifestyle Assessment Word Program English
DPH F-01220S WISEWOMAN Healthy Lifestyle Assessment - Spanish Word Program Spanish
DPH F-01221 WISEWOMAN Screening Activity Word Program English
DPH F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral Word Program English
DPH F-01223 WISEWOMAN Case Management Word Program English
DPH F-01224 WISEWOMAN Healthy Behavior Initial Support Word Program English
DPH F-01225 WISEWOMAN Health Coaching Follow-Up Word Program English
DPH F-01226 WISEWOMAN Lifestyle Program Follow-Up Word Program English
DPH F-01227 WISEWOMAN Healthy Behavior Readiness Assessment Follow-Up Word Program English
DPH F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment Word Program English
DPH F-01229 WISEWOMAN Provider Assurances and Training Checklist Word Program English
DLTC F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application Word None English
DHCAA F-01234 Medical Benefits Explanation (PDF, 4048 KB) PDF None English
DHCAA F-01234 Medical Benefits Explanation Word None English
DHCAA F-01234A Medical Benefits Explanation Coimpletion Instructions (PDF, 128 KB) PDF None English
DLTC F-01240 IRIS Critical Incident Reconciliation Word None English
DLTC F-01246 Background Information Disclosure Addendum—IRIS Word None English
DHCF F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) (PDF, 620 KB) PDF None English
DHCF F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) Word None English
DHCF F-01247-1 Prior Authorization Drug Attachment for Sovaldi (Effective for use prior to December 1, 2014) (PDF, 589 KB) PDF None English
DHCF F-01247-1 Prior Authorization Drug Attachment for Sovaldi (Effective for use prior to December 1, 2014) Word None English
DHCF F-01247A Prior Authorization Drug Attachment for Hepatitis C Agents Completion Instructions (Effective for use on and after December 1, 2014) (PDF, 60 KB) PDF None English
DHCF F-01247A-1 Prior Authorization Drug Attachment for Sovaldi Completion Instructions (Effective for use prior to December 1, 2014) (PDF, 58 KB) PDF None English
DHCF F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) (PDF, 568 KB) PDF None English
DHCF F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) Word None English
DHCF F-01248-1 Prior Authorization Drug Attachment for Sovaldi Renewal (Effective for use prior to December 1, 2014) (PDF, 540 KB) PDF None English
DHCF F-01248-1 Prior Authorization Drug Attachment for Sovaldi Renewal (Effective for use prior to December 1, 2014) Word None English
DHCF F-01248A Prior Authorization Drug Attachment for Heaptitis C Agents Completion Instructions (Effective for use on and after December 1, 2014) (PDF, 40 KB) PDF None English
DHCF F-01248A-1 Prior Authorization Drug Attachment for Sovaldi Renewal Completion Instructions (Effective for use prior to December 1, 2014) (PDF, 23 KB) PDF None English
DHCF F-01249 Prior Authorization Drug Attachment for Stribild (PDF, 541 KB) PDF None English
DHCF F-01249 Prior Authorization Drug Attachment for Stribild Word None English
DHCF F-01249A Prior Authorization Drug Attachment for Stribild Completion Instructions (PDF, 23 KB) PDF None English
DHCF F-01252 FoodShare Employment and Training - Initial Appointment Letter Word None English
DHCF F-01253 FoodShare Employment and Training - Final Notice Appointment Letter Word None English
DHCF F-01254 FoodShare Employment and Training - Employment Plan (EP) Appointment Letter Word None English
DHCF F-01255 FoodShare Employment and Training - Job Club Appointment Letter Word None English
DHCF F-01256 FoodShare Employment and Training - Discuss Participant Appointment Letter Word None English
DHCF F-01257 FoodShare Employment and Training - Workshop Appointment Letter Word None English
DLTC F-01258 IRIS Self - Directed Personal Care (SDPC) Disclosure Statement Word None English
DLTC F-01261 Fraud Statement - IRIS Program Word None English
DLTC F-01262 IRIS Involuntary Disenrollment Request - Fraud Word None English
DLTC F-01264 Service Fund Application for Reimbursement PDF None English
DLTC F-01264 Service Fund Application for Reimbursement Word None English
DLTC F-01267 Aging and Disability Resource Center (ADRC) Complaint Report Word None English
DMHSAS F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility Word None English
DHCAA F-01270 Comprehensive Community Services Non-Traditional Approval PDF None English
DHCAA F-01270 Comprehensive Community Services Non-Traditional Approval Word None English
DLTC F-01275 IRIS Provider Board Member Disclosure Word None English
DLTC F-01278 Program Participation System (PPS) Employment Questions Word None English
DLTC F-01279 Program Participation System (PPS) Employment Interview Word None English
DLTC F-01281 Letter - Notice to Current COP Participants-Model Word None English
DLTC F-01281A Letter - Notice to Current COP-W, CIP and Brain Injury Waiver Participants-Model Word None English
DLTC F-01282 Monthly Enrollment Discrepancy Report Template-Model Excel None English
DLTC F-01283 Notification of Non-Covered Benefit Letter Template-Model Word None English
DLTC F-01284 Quarterly MCO Financial Report Template-Model Excel None English
DLTC F-01285 Quarterly MCO Consolidated Financial Report Template-Model Excel None English
DLTC F-01286 Transition - Final Plan Template-Model Excel None English
DLTC F-01286a Initial and Final Transition Plans - Instructions (PDF, 139 KB) PDF None English
DLTC F-01287 Transition - Initial Plan Template-Model Excel None English
DLTC F-01293 Participant Fiscal Employer Agent (FEA) Selection Word None English
DLTC F-01293A Participant Fiscal Employer Agent (FEA) Selection - Change Word None English
HCF-01302 F-01302 Weekly Driver's Vehicle Inspection Report (PDF, 113 KB) PDF None English
HCF-01302 F-01302 Weekly Driver's Vehicle Inspection Report Word None English
HCF-01302A F-01302A Weekly Driver's Vehicle Inspection Report Instructions (PDF, 25 KB) PDF None English
DLTC F-01308 IRIS Program Annual Review Checklist Word None English
DLTC F-01309 IRIS Program Orientation and Enrollment Checklist Word None English
DLTC F-01310 IRIS Program Conflict of Interest Disclosure – Provider Word None English
DLTC F-01310A IRIS Program Conflict of Interest Disclosure - Participant Word None English
DLTC F-01312 IRIS Provider Application Word None English
DPH F-01313 Register to Reschedule Lead (Pb) Certification Exam Word Program English
DLTC F-01314 IRIS Program Employment Checklist Word None English
DLTC F-01319 IRIS Involuntary Disenrollment Request Word None English
  F-01320 Lead Test Kit Documentation Word Program English
DLTC F-01322 ADRC Activity Reporting Template-Model Excel None English
DMHSAS F-01332 Predispositional Investigation Report (PDI) Word None English
DMHSAS F-01336 Wisconsin Assessment of the Impaired Driver (WAID) and Other Substance Users Paper Form Center English
DLTC F-01337 Worksheet for Determination of Parental Payment Limit for CLTS Excel None English
DLTC F-01338 CLTS Parental Fee Declaration-Model Word None English
DMHSAS F-01339 Person-Centered Planning Fidelity Checklist Word None English
DMHSAS F-01341 Pre-Release from Institution Checklist (CM Checklist) Word None English
DLTC F-01344 Strategies for Success with People Who Have Dementia-Behavior Analysis Worksheet-Model (PDF, 92 KB) PDF None English
DLTC F-01345 Special Care Environment Working Document PDF None English
DLTC F-01346 Behavior Monitoring Record-Model (PDF, 144 KB) PDF None English
DLTC F-01348 Determining the Weighted Care Management Rate-Direct Service Staff Worksheet CM-I (Model) (PDF, 37 KB) PDF None English
DLTC F-01348A Ratio Method, Add-On Indirect Care Management Support Costs Worksheet CM-II (Model) (PDF, 40 KB) PDF None English
DLTC F-01348B Itemized Method-A Administration and Support Staff Worksheet CM-III (a) (Model) (PDF, 37 KB) PDF None English
DLTC F-01348C Itemized Method-B Non-salary Cost Worksheet CM-III (b) (Model) (PDF, 89 KB) PDF None English
DLTC F-01349 Substitute Care Model Quality Performance Standards & Measures (Model) (PDF, 172 KB) PDF None English
DLTC F-01350 Initial/Recertification Service Plan Checklist (Model) (PDF, 27 KB) PDF None English
DLTC F-01352 Background Check Appeal Request - IRIS Program Word None English
  F-01359 Historical Earnings Verification Request Word None English
  F-01361 ForwardHealth Provider Express Enrollment Change of Address System None English
DPH F-01367 Wisconsin WIC Referral/Communication to CYSHCN Regional Center Word None English
DLTC F-01381 Medicaid Administrative Pass -Through (MAPT) Time Summary Excel None English
DMHSAS F-01389 Recovery Oriented System Indicators (ROSI) Adult Satisfaction Survey (PDF, 195 KB) PDF None English
DMHSAS F-01389A Mental Health Statistical Improvement Program (MHSIP) Youth Satisfaction Survey (PDF, 165 KB) PDF None English
DMHSAS F-01389B Mental Health Statistical Improvement Program (MHSIP) Family Satisfaction Survey (PDF, 166 KB) PDF None English
DMHSAS F-01391 Recovery Oriented System Indicators (ROSI) Adult Data Workbook Excel None English
DMHSAS F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook Excel None English
DMHSAS F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook Excel None English
DMHSAS F-01402 Test Your Knowledge About Trauma-Informed Care (PDF, 164 KB) PDF None English
DLTC F-01415 IRIS Adult Family Home Taxable Income Information Word None English
DMHSAS F-01416 Coordinated Service Team (CST) Initiative Detailed Budget Plan Excel None English
HCF-01501 F-01501 Private Duty Nursing to Ventilator-Dependent Members Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01502 F-01502 Private Duty Nursing Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01504 F-01504 Nurse Midwife Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01506 F-01506 Medical Supply and Equipment Vendor Terms of Reimbursement (PDF, 34 KB) PDF None English
HCF-01507 F-01507 Mental Health / Substance Abuse Services Terms of Reimbursement (PDF, 61 KB) PDF None English
HCF-01509 F-01509 Nurse Practitioner Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01512 F-01512 Occupational Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01514 F-01514 Optometrist / Optician Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01516 F-01516 Personal Care Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01518 F-01518 Pharmacy Terms of Reimbursement (PDF, 49 KB) PDF None English
HCF-01520 F-01520 Physical Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01523 F-01523 Physician and Physician Assistant Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01525 F-01525 Podiatrist Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01527 F-01527 Portable X-Ray Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01529 F-01529 PreNatal Care Coordination Agency Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01531 F-01531 Rehabilitation Agency Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01533 F-01533 Rural Health Clinic Terms of Reimbursement (PDF, 44 KB) PDF None English
HCF-01535 F-01535 School-Based Services Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01537 F-01537 Specialized Medical Vehicle Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01539 F-01539 Wisconsin Chronic Disease Program Provider Enrollment (PDF, 354 KB) PDF None English
HCF-01540 F-01540 Wisconsin Chronic Disease Program Provider Application and Instructions PDF None English
HCF-01541 F-01541 Wisconsin Chronic Disease Program Provider Agreement and Acknowledgement of Terms of Participation (Standard for Individual and Clinic / Group / Agency Providers) PDF None English
HCF-01812 F-01812 Wisconsin Medicaid Program Nursing Home Cost Report Excel 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
DPH-04002 F-04002 School Report to Local Health Department (PDF, 320 KB) PDF None English
DPH F-04003 WIC Vendor Monitoring Worksheet - Retail Grocery Stores PDF None English
DPH-04020 F-04020 Student Immunization Record - This form is intended for Schools Paper Form Center English
DPH-04020L F-04020L Student Immunization Record, Long (PDF, 303 KB) PDF Form Center English
DPH-04020LH F-04020LH Student Immunization Record, Long - Hmong (PDF, 84 KB) PDF Form Center Hmong
DPH-04020LS F-04020LS Student Immunization Record, Long - Spanish (PDF, 50 KB) PDF Form Center Spanish
DPH-04021 F-04021 Age Grade Level Requirements Paper Program English
DPH-04021S F-04021S Age Grade Level Requirements - Spanish Paper Program Spanish
DPH-05004 F-05004 Birth Amendment - Affidavit Paper Program English
DPH-05020 F-05020 Paternity Order Due to Divorce - Judgement Paper Program English
DPH-05020A F-05020A Paternity Order Due to Divorce - Custody Paper Program English
DPH-05021 F-05021 Report of Legal Name Change Paper Form Center English
DPH F-05021C Report of Legal Name Change - Confidential Paper User English
DPH-05021T F-05021T Report of Legal Name Change - Tribal Paper None English
DPH-05022 F-05022 Report of Adoption Paper Program English
DPH-05022F F-05022F Report of Adoption - Child Born In A Foreign Country Paper Program English
DPH-05022T F-05022T Report of Adoption - Tribal Paper Program English
DPH-05023 F-05023 Acknowledgement of Marital Child Restricted Program English
DPH-05024 F-05024 Voluntary Paternity Acknowledgement Paper Program English
DPH-05024S F-05024IS Voluntary Paternity Acknowledgement Instructions - Spanish Paper Program Spanish
DPH-05024 F-05024S Voluntary Paternity Acknowledgement - Spanish Paper Program Spanish
DPH-05027A F-05027A Report of Citizenship Paper Program English
DPH-05027B F-05027B Report of Naturalization Paper Program English
DPH-05029 F-05029 Request To Withdraw Voluntary Paternity Acknowledgement (PDF, 42 KB) PDF Program English
DPH-05032 F-05032 Report of Birth Certificate Changes After Surrogate Birth (PDF, 42 KB) PDF Program English
DPH-05033 F-05033 Birth Amendment - Baptismal Paper Program English
DPH-05034 F-05034 Birth Certificate Facts Paper Program English
DPH-05035 F-05035 Report Change Name, Sex Birth Certificate Surgical Procedure Word Program English
DPH-05043 F-05043 Notice of Removal - Corpse (Hospital, Nursing Home, Hospice) Paper Program English
DPH-05044 F-05044 Cause of Death Amendment Paper Program English
DPH-05044C F-05044C Corner/Medical Examiner - Cause of Death Amendment Word Program English
DPH-05045 F-05045 Report for Final Disposition Paper Program English
DPH-05046 F-05046 Delayed Death - Court Order Paper Program English
DPH-05054 F-05054 Court Order To Amend Cause of Death - 89 Paper Program English
DPH-05098 F-05098 Court Order to Correct Facts, Misrepresented Information Paper Program English
DPH-05102 F-05102 Wisconsin Immunization Registry Exclusion Paper Program English
DPH-05103 F-05103 Facts About Your Child's Birth Certificate Paper Form Center English
DPH-05104 F-05103S Facts About Your Child's Birth Certificate - Spanish Paper Form Center Spanish
DPH-05191 F-05191 Vital Records Fee Schedule--Now numbered P-05191 Paper Form Center English
DPH-05210 F-05210 Name Change Request Within 1st Year Paper Program English
DPH-05218 F-05218 E-mail Notification Request For New Publication Release HTML None English
DPH-05260 F-05260 Letter of Non-Marriage Application (PDF, 72 KB) PDF None English
DPH F-05260S Letter of Non-Marriage Application -Spanish (PDF, 117 KB) PDF None Spanish
DPH-05280 F-05280 Death Certificate Application (PDF, 72 KB) PDF None English
DPH-05280S F-05280S Death Certificate Application - Spanish (PDF, 118 KB) PDF None Spanish
DPH-05281 F-05281 Marriage Certificate Application - Wisconsin (PDF, 78 KB) PDF None English
DPH-05281S F-05281S Marriage Certificate Application - Wisconsin - Spanish (PDF, 76 KB) PDF None Spanish
DPH-05282 F-05282 Divorce Certificate Application - Wisconsin (PDF, 60 KB) PDF None English
DPH-05282S F-05282S Divorce Certificate Application - Wisconsin - Spanish (PDF, 107 KB) PDF None Spanish
DPH-05283 F-05283 Veterans Application Restricted Program English
DPH-05291 F-05291 Birth Certificate Application - Wisconsin (PDF, 88 KB) PDF None English
DPH-05291S F-05291S Birth Certificate Application - Wisconsin - Spanish (PDF, 135 KB) PDF None Spanish
DPH-05292 F-05292 FAX Request for Wisconsin Birth Certificate (PDF, 82 KB) PDF None English
DPH-05292S F-05292S FAX Request for Wisconsin Birth Certificate - Spanish (PDF, 95 KB) PDF None Spanish
DPH-05294 F-05294 FAX Request for Wisconsin Marriage Certificate (PDF, 71 KB) PDF None English
DPH-05294S F-05294S FAX Request for Wisconsin Marriage Certificate - Spanish (PDF, 108 KB) PDF None Spanish
DPH-05296 F-05296 FAX Request for Wisconsin Divorce Certificate (PDF, 84 KB) PDF None English
DPH-05296S F-05296S FAX Request for Wisconsin Divorce Certificate - Spanish (PDF, 131 KB) PDF None Spanish
DPH-05297 F-05297 FAX Request for Wisconsin Death Certificate (PDF, 99 KB) PDF None English
DPH-05297S F-05297S FAX Request for Wisconsin Death Certificate - Spanish (PDF, 75 KB) PDF None Spanish