Department of Health Services Logo

 

Wisconsin Department of Health Services

Forms Home

Publications Home

About PDF Documents

Alphabetic Forms Lists

A - E

F - M

N - Z

Numeric Lists

Division/Office
Numeric Lists

CFS
DES
DLTC
DMHSAS
DPH
DQA
DHCAA
DHS
EXS
OIG

Division Prefix Definitions

Cannot Find a Form?

Order Printed Forms

Order WI  Administrative Codes or Statutes

 

Forms: F to M

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
DQA F-62372S Facilidad Residencial Basada en la Comunidad (CBRF) Evaluacion de Satisfacction al Cliente Word None Spanish
DQA F-62372S Facilidad Residencial Basada en la Comunidad (CBRF) Evaluacion de Satisfacction al Cliente (PDF, 23 KB) PDF None Spanish
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
OQA-2611 F-62611 Family Adult Day Care Certification Standards Checklist Word None English
OQA-2611 F-62611 Family Adult Day Care Certification Standards Checklist (PDF, 51 KB) PDF None English
DLTC F-00681A Family Care - Managed Care Organization (MCO) Options Word None English
DLTC F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan Word None English
DLTC F-00221 Family Care / IRIS Member Requested Disenrollment Word None English
DLTC F-00221i Family Care / IRIS Member Requested Disenrollment - Instructions (PDF, 26 KB) PDF 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-00265 Family Care Centralized Enrollment Spreadsheet Excel None English
DLTC F-00046 Family Care Program Enrollment Instructions and Important Information Word None English
DMT-0783A F-80783A Family Financial Questionnaire - County Use Word None English
DMT-0783A F-80783A Family Financial Questionnaire - County Use (PDF, 30 KB) PDF None English
HCF-01099 F-01099 Family Planning Clinic Terms of Reimbursement (PDF, 42 KB) PDF None English
DHCAA F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application (PDF, 25 KB) PDF None English
DDE-0851 F-20851 Family Support Program Functional Screen (PDF, 26 KB) PDF None English
DDE-0851A F-20851A Family Support Program Functional Screen - Newborns and Young Infants (PDF, 11 KB) PDF None English
DDE-0851B F-20851B Family Support Program Functional Screen - Older Infants and Toddlers (PDF, 11 KB) PDF None English
DDE-0851C F-20851C Family Support Program Functional Screen - Pre-School Children (PDF, 11 KB) PDF None English
DDE-0851D F-20851D Family Support Program Functional Screen - School Age Children (PDF, 11 KB) PDF None English
DDE-0851E F-20851E Family Support Program Functional Screen - Young Adolescents (PDF, 11 KB) PDF None English
DDE-0851F F-20851F Family Support Program Functional Screen Older Adolescents (PDF, 11 KB) PDF None English
DDE-0851G F-20851G Family Support Program Functional Screen Screening for Severe Emotional Disturbance (All Ages) (PDF, 17 KB) PDF None English
DPH-04800 F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers (PDF, 36 KB) PDF None English
DPH-40053 F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training (PDF, 10 KB) PDF None English
DPH F-00127 Fax Application Declaration Wisconsin Domestic Partnership (PDF, 63 KB) PDF None English
DPH F-00126 Fax Application Declaration Wisconsin Domestic Partnership (PDF, 84 KB) PDF None English
DPH F-00127S Fax Application Declaration Wisconsin Domestic Partnership - Spanish (PDF, 123 KB) PDF None Spanish
DPH F-00126S Fax Application Declaration Wisconsin Domestic Partnership - Spanish (PDF, 63 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-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-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-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
HCF-01108 F-01108 Federally Qualified Health Center Terms of Reimbursement (PDF, 42 KB) PDF None English
OQA-2588 F-62588 Feeding Assistant Training Program Application Word None English
OQA-2588 F-62588 Feeding Assistant Training Program Application (PDF, 76 KB) PDF None English
DQA F-62692 Feeding Assistant Training Program Primary Instructor Application Word None English
DQA F-62692 Feeding Assistant Training Program Primary Instructor Application (PDF, 28 KB) PDF None English
DQA F-62688 Feeding Assistant Training Program Trainer Application Word None English
DQA F-62688 Feeding Assistant Training Program Trainer Application (PDF, 25 KB) PDF None English
DQA F-00015 Final Occupancy Inspection Checklist Word None English
DQA F-00015 Final Occupancy Inspection Checklist (PDF, 21 KB) PDF None English
DMT-0130 F-80130 Financial Information (PDF, 90 KB) PDF None English
DMT-0130H F-80130H Financial Information - Hmong (PDF, 196 KB) PDF None Hmong
DMT-0130S F-80130S Financial Information - Spanish Word None Spanish
DMT-0130S F-80130S Financial Information - Spanish (PDF, 81 KB) PDF None Spanish
DMT-0130 F-80130 Financial Information  Word None English
DHCAA F-00407 Financial Records Request (PDF, 28 KB) PDF None English
OQA-2500 F-62500 Fire Report Word None English
OQA-2500 F-62500 Fire Report (PDF, 34 KB) PDF None English
DPH-07478 F-47478 First Responder / Emergency Medical Technician Application Electronic Addition to a Roster System None English
DPH-07477 F-47477 First Responder / Emergency Medical Technician Certificate / License System None English
DPH-07181 F-47181 First Responder Certification Card System None English
DPH-07463A F-47463A First Responder Operational Plan Components (PDF, 19 KB) PDF None English
DLTC F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request Excel None English
DQA F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries (PDF, 19 KB) PDF None English
DPH-04819 F-44819 FMNP - Application for Farmstands (PDF, 28 KB) PDF None English
DPH-04746 F-44746 FMNP - Site Observation Worksheet (PDF, 15 KB) PDF None English
DPH-40103 F-40103 FMNP Senior Eligibility Agreement (PDF, 104 KB) Paper Form Center English
DPH-40103H F-40103H FMNP Senior Eligibility Agreement - Hmong (PDF, 141 KB) Paper Form Center English
DPH-40103S F-40103S FMNP Senior Eligibility Agreement - Spanish (PDF, 143 KB) Paper Form Center English
HCF-16076 F-16076 FoodShare and/or Child Care Six Month Report Word None English
HCF-16076AS F-16076AS FoodShare and/or Child Care Six Month Report Instructions - Spanish Word None Spanish
HCF-16076H F-16076H FoodShare and/or Child Care Six Month Report (Hmong) Word None Hmong
HCF-16076S F-16076S FoodShare and/or Child Care Six Month Report - Spanish Word None Spanish
HCF-16076A F-16076A FoodShare and/or Child Care Six Month Report Form Instructions Word None English
HCF-16076AH F-16076AH FoodShare and/or Child Care Six Month Report Form Instructions - Hmong Word None Hmong
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
DHCF F-01256 FoodShare Employment and Training - Discuss Participant Appointment Letter Word None English
DHCF F-01254 FoodShare Employment and Training - Employment Plan (EP) Appointment Letter Word None English
DHCF F-01253 FoodShare Employment and Training - Final Notice Appointment Letter Word None English
DHCF F-01252 FoodShare Employment and Training - Initial Appointment Letter Word None English
DHCF F-01255 FoodShare Employment and Training - Job Club Appointment Letter Word None English
DHCF F-01257 FoodShare Employment and Training - Workshop Appointment Letter Word 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
HCF-16019B F-16019B FoodShare Wisconsin Application / Registration (PDF, 657 KB) Paper Form Center English
HCF-16019BH F-16019BH FoodShare Wisconsin Application / Registration - Hmong (PDF, 712 KB) PDF None Hmong
HCF-16019BS F-16019BS FoodShare Wisconsin Application / Registration - Spanish (PDF, 677 KB) PDF None Spanish
HCF-16006 F-16006 FoodShare Wisconsin Change Report (PDF, 250 KB) Paper Form Center English
HCF-16006H F-16006H FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) PDF None Hmong
HCF-16006S F-16006S FoodShare Wisconsin Change Report - Spanish (PDF, 133 KB) PDF None Spanish
HCF-16066 F-16066 FoodShare Wisconsin Income Change Report (PDF, 171 KB) Paper Form Center English
HCF-16066H F-16066H FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) PDF None Hmong
HCF-16066S F-16066S FoodShare Wisconsin Income Change Report - Spanish (PDF, 87 KB) PDF None Spanish
HCF-16073 F-16073 FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) PDF None English
HCF-16019A F-16019A FoodShare Wisconsin Registration / Important Information (PDF, 170 KB) Paper Form Center English
HCF-16019AH F-16019AH FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 238 KB) PDF None Hmong
HCF-16019AS F-16019AS FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 299 KB) PDF None Spanish
HCF-16029 F-16029 FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) PDF None English
HCF-16029S F-16029S FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) PDF None Spanish
HCF-16030 F-16030 FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) PDF None English
HCF-16033 F-16033 FoodShare Worksheet (PDF, 45 KB) PDF None English
DES F-00255 Forms / Publications / Records Management Survey System None English
DMT-0025 F-80025 Forms / Publications Requisition Paper Form Center English
DMT-0025A F-80025A Forms / Publications Requisition Word None English
DMT-0025B F-80025B Forms / Publications Requisition Word None English
DDE-0920 F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care Excel None English
DDE-0920 F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care (PDF, 22 KB) PDF None English
  F-01361 ForwardHealth Provider Express Enrollment Change of Address System None English
DLTC F-00113 Four Conditions for the Use of Funding in a CBRF Word None English
DLTC F-01261 Fraud Statement - IRIS Program Word None English
DDE-2553A F-22553A Free In-Service or Educational Training Request (PDF, 35 KB) PDF None English
HCF-01094 F-01094 Free Standing End-Stage Renal Disease Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
OQA-2496 F-62496 Free-Standing CBRF Plan Approval Application Word None English
OQA-2496 F-62496 Free-Standing CBRF Plan Approval Application (PDF, 52 KB) PDF None English
DMHSAS F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services (PDF, 77 KB) PDF None English
DLTC/DMHSAS F-00037 Functional Screen Listserv Sign-Up HTML None English
OQA-9306 F-69306 General Observations of The Facility CMS-803 Paper Form Center English
DPH F-45021 Generally Licensed Device Inspection by Mail (PDF, 20 KB) PDF None English
DPH F-45021 Generally Licensed Device Inspection by Mail Word None English
HCF-10111 F-10111 Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) PDF None English
HCF-10111A F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) PDF None English
DLTC F-01212 Grievance Form--IRIS Program Word None English
DDE-9323 F-29323 Hardship Policy / Hidden Asset Policy (PDF, 19 KB) PDF None English
DPH-07204 F-47204 Hazard Summary Form Paper Program English
DLTC F-00004B Health and Employment Counseling - I Have Reached Employment (PDF, 23 KB) PDF None English
DLTC F-00004A Health and Employment Counseling - I Think I Need More Time (PDF, 35 KB) PDF None English
DLTC F-00004 Health and Employment Counseling Application Word None English
DPH-43006 F-43006 Health Care Facility Assurance for J-1 Visa Waiver Applications (PDF, 653 KB) PDF None English
OQA-2494 F-62494 Health Care Facility Construction Documentation Checklist Word None English
OQA-2494 F-62494 Health Care Facility Construction Documentation Checklist (PDF, 28 KB) PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review Word None English
HCF-01062 F-01062 HealthCheck Adolescent Review (PDF, 129 KB) PDF None English
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish Word None Spanish
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish (PDF, 131 KB) PDF 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, 14 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-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey Word None English
HCF-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey (PDF, 127 KB) PDF None English
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish Word None Spanish
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish (PDF, 80 KB) PDF None Spanish
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit Word None English
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit (PDF, 95 KB) PDF None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit Word None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit (PDF, 91 KB) PDF None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit Word None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit (PDF, 94 KB) PDF None English
HCF-01068I F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit Word None English
HCF-01068I F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit (PDF, 133 KB) PDF None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit Word None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit (PDF, 108 KB) PDF None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit Word None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit (PDF, 87 KB) PDF None English
HCF-01068C F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit Word None English
HCF-01068D F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit (PDF, 102 KB) PDF None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 to 8 Week Visit Word None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 to 8 Week Visit (PDF, 71 KB) PDF None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit Word None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit (PDF, 88 KB) PDF None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit Word None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit (PDF, 83 KB) PDF None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit Word None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit (PDF, 93 KB) PDF None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit Word None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit (PDF, 95 KB) PDF None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF, 13 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 Word None Spanish
HCF-01066AS F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age - Spanish (PDF, 15 KB) PDF None Spanish
HCF-01063 F-01063 HealthCheck Family History Word None English
HCF-01063 F-01063 HealthCheck Family History (PDF, 280 KB) PDF None English
HCF-01063S F-01063S HealthCheck Family History - Spanish Word None Spanish
HCF-01063S F-01063S HealthCheck Family History - Spanish (PDF, 277 KB) PDF None Spanish
HCF-01002 F-01002 HealthCheck Individual Health History Word None English
HCF-01002 F-01002 HealthCheck Individual Health History (PDF, 797 KB) PDF None English
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong Word None Hmong
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong (PDF, 861 KB) PDF None Hmong
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish Word None Spanish
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish (PDF, 434 KB) PDF None Spanish
HCF-01066 F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) Word None English
HCF-01066 F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (PDF, 13 KB) PDF None English
HCF-01066S F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age) - Spanish 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-01113 F-01113 HealthCheck Other Services Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
OIG F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01114 F-01114 HealthCheck Screener and Case Management Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01112 F-01112 HealthCheck Verification Card Paper Form Center English
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing Word None English
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing (PDF, 280 KB) PDF None English
DPH F-00355 Healthiest Wisconsin 2020 Implementation Plan Endorsement Word None English
HCF-01083 F-01083 Hearing Instrument Specialist Terms of Reimbursement (PDF, 52 KB) PDF None English
DDE-2554 F-22554 Hearing Loss Certification Telecommunications Assistance Program* (PDF, 20 KB) PDF None English
DPH-40123A F-40123A Hearing Screening Postcard - English Paper Form Center English
DPH-40123AH F-40123AH Hearing Screening Postcard - Hmong Paper Form Center English
DPH-40123AS F-40123AS Hearing Screening Postcard - Spanish Paper Form Center English
  F-01359 Historical Earnings Verification Request Word None English
DQA F-62646 Home Health Agency (HHA) Patient Rights Statement Review Word None English
DQA F-62646 Home Health Agency (HHA) Patient Rights Statement Review (PDF, 23 KB) PDF None English
DQA F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits Word None English
DQA F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits (PDF, 12 KB) PDF None English
DQA F-62680 Home Health Agency Clinical Record Review Word None English
DQA F-62680 Home Health Agency Clinical Record Review (PDF, 22 KB) PDF None English
OQA-2069 F-62069 Home Health Agency Complaint Report Word None English
OQA-2069 F-62069 Home Health Agency Complaint Report (PDF, 34 KB) PDF None English
DQA F-62657 Home Health Agency Contract Review Worksheet Word None English
DQA F-62657 Home Health Agency Contract Review Worksheet (PDF, 12 KB) PDF None English
OQA-2674 F-62674 Home Health Agency License Application Restricted None English
DQA F-62653 Home Health Agency Licensure Survey Entrance Conference Guide Word None English
DQA F-62653 Home Health Agency Licensure Survey Entrance Conference Guide (PDF, 14 KB) PDF None English
DQA F-62654 Home Health Agency Licensure Survey Exit Conference Guide Word None English
DQA F-62654 Home Health Agency Licensure Survey Exit Conference Guide (PDF, 14 KB) PDF None English
DQA F-62652 Home Health Agency Licensure Survey Home Visit Guide Word None English
DQA F-62652 Home Health Agency Licensure Survey Home Visit Guide (PDF, 20 KB) PDF None English
DQA F-62231 Home Health Agency Personnel Record Review Word None English
DQA F-62231 Home Health Agency Personnel Record Review (PDF, 10 KB) PDF None English
DQA F-62536 Home Health Agency Prelicensure Desk Review Checklist Word None English
DQA F-62536 Home Health Agency Prelicensure Desk Review Checklist (PDF, 28 KB) PDF None English
DQA F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) Word None English
DQA F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) (PDF, 13 KB) PDF None English
HCF-01121 F-01121 Home Health Agency Terms of Reimbursement (PDF, 41 KB) PDF None English
DDE-1055 F-21055 Home Modification Request for a Ramp Word None English
DDE-1055 F-21055 Home Modification Request for a Ramp (PDF, 26 KB) PDF None English
DQA F-62236 Hospice Clinical Record Review Word None English
DQA F-62236 Hospice Clinical Record Review (PDF, 27 KB) PDF None English
OQA-2519 F-62519 Hospice Comparisons of State (DHS 131) and Federal Conditions of Participation Word None English
OQA-2519 F-62519 Hospice Comparisons of State (DHS 131) and Federal Conditions of Participation (PDF, 177 KB) PDF None English
OQA-2287 F-62287 Hospice Complaint Report Word None English
OQA-2287 F-62287 Hospice Complaint Report (PDF, 37 KB) PDF None English
DQA F-62232 Hospice Contracts and Agreements Review Word None English
DQA F-62232 Hospice Contracts and Agreements Review (PDF, 21 KB) PDF None English
DQA F-62322 Hospice Inpatient Clinical Record Review Word None English
DQA F-62322 Hospice Inpatient Clinical Record Review (PDF, 23 KB) PDF None English
DQA F-62641 Hospice Inpatient Symptom Management and Respite Contract or Agreement Review Word None English
DQA F-62641 Hospice Inpatient Symptom Management and Respite Contract or Agreement Review (PDF, 16 KB) PDF None English
OQA-2062 F-62062 Hospice License Application Restricted None English
DQA F-62316 Hospice Patient Rights Word None English
DQA F-62316 Hospice Patient Rights (PDF, 15 KB) PDF None English
DQA F-62233 Hospice Personnel Record Review Word None English
DQA F-62233 Hospice Personnel Record Review (PDF, 14 KB) PDF None English
DQA F-62321 Hospice Program Review Word None English
DQA F-62321 Hospice Program Review (PDF, 13 KB) PDF None English
DQA F-62318 Hospice Quality Assessment and Performance Improvement Reivew Word None English
DQA F-62318 Hospice Quality Assessment and Performance Improvement Reivew (PDF, 14 KB) PDF None English
DQA F-62320 Hospice Survey Information Word None English
DQA F-62320 Hospice Survey Information (PDF, 15 KB) PDF None English
HCF-01125 F-01125 Hospice Terms of Reimbursement (PDF, 41 KB) PDF None English
DQA F-62319 Hospice Volunteer Program Review Word None English
DQA F-62319 Hospice Volunteer Program Review (PDF, 14 KB) PDF None English
HCF-01095 F-01095 Hospital Affiliated End-Stage Renal Disease Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
OQA-2092 F-62092 Hospital Certificate of Approval Application Word None English
OQA-2092 F-62092 Hospital Certificate of Approval Application (PDF, 82 KB) PDF None English
HCF-01128 F-01128 Hospital Terms of Reimbursement (PDF, 41 KB) PDF None English
DPH-07009 F-47009 Hotel / Motel or Tourist Rooming House Inspection Report Paper Program English
  F-00985H How the Affordable Care Act may affect SeniorCare members who get Prescriptions (Hmong) (PDF, 72 KB) PDF None Hmong
DHCAA F-00985 How the Affordable Care Act may affect SeniorCare members who get Prescriptions (PDF, 62 KB) PDF None English
  F-00985S How the Affordable Care Act may affect SeniorCare members who get Prescriptions (Spanish) (PDF, 71 KB) PDF None Spanish
EXEC F-00024 HSRS Core Summary Report Excel None English
DES F-20468i HSRS Family Support Module Deskcard (PDF, 17 KB) PDF None English
DES F-20468 HSRS FSP Module and Expenditures Paper Form Center English
DES F-20468 HSRS FSP Module and Expenditures Word Form Center English
DDE-2018 F-22018 HSRS Long-Term Support Module Word Form Center English
DDE-2018 F-22018 HSRS Long-Term Support Module (PDF, 51 KB) PDF Form Center English
DDE-2018I F-22018i HSRS Long-Term Support Module Desk Card - Booklet (PDF, 39 KB) PDF None English
EXEC F-22540 Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs System None English
EXEC F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet Excel None English
DLTC F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program Word None English
DPH F-44815 Immunization Program Orders (Medical Authorization), Policy and Procedure Approval, and Indemnification Word Program English
DPH F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR) Excel 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
DDE-2541 F-22541 Incident Report - Medicaid Waiver Programs Word None English
DDE-2541 F-22541 Incident Report - Medicaid Waiver Programs (PDF, 58 KB) PDF None English
OQA-2447 F-62447 Incident Report of Caregiver Misconduct and Injuries of Unknown Source Word None English
OQA-2447 F-62447 Incident Report of Caregiver Misconduct and Injuries of Unknown Source (PDF, 102 KB) PDF None English
DLTC F-22541i Incident Reporting - Medicaid Waiver Programs, Instructions (PDF, 51 KB) PDF None English
HCF-16083 F-16083 Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) PDF None English
OQA-2569 F-62569 Individual Provider Status Approval Application Word None English
OQA-2569 F-62569 Individual Provider Status Approval Application (PDF, 38 KB) PDF None English
DMHSAS F-00202 Individual Service Plan - Community Recovery Services (CRS) Word None English
DMHSAS F-00202i Individual Service Plan - Community Recovery Services (CRS) - Instructions Word None English
DDE-0445A F-20445A Individual Service Plan - Individual Outcomes Word None English
DDE-0445A F-20445A Individual Service Plan - Individual Outcomes (PDF, 39 KB) PDF None English
DMHSAS F-00202A Individual Service Plan - Individual Outcomes, Community Recovery Services (CRS) Word None English
DDE-0445 F-20445 Individual Service Plan - MA Waivers (PDF, 51 KB) PDF None English
DDE-0445 F-20445 Individual Service Plan - Medicaid Waivers Word None English
DLTC F-00989 Individualized Family Service Plan (IFSP) Word None English
OQA-2514 F-62514 Informal Dispute Resolution (IDR) Request Word None English
DQA F-62069S Informe de Queja de Agencia de Cuidado de Salud en el Hogar (Home Health Agency Complaint Report - Spanish) Word None Spanish
DQA F-62069S Informe de Queja de Agencia de Cuidado de Salud en el Hogar (Home Health Agency Complaint Report - Spanish) (PDF, 29 KB) PDF None Spanish
DQA F-62287S Informe de Queja de Hospicio Word None Spanish
DQA F-62287S Informe de Queja de Hospicio (PDF, 43 KB) PDF None Spanish
DDE-1076 F-21076 Informed Consent - Children's Long-Term Support Functional Screen Word None English
DLTC F-21076H Informed Consent - Children's Long-Term Support Functional Screen - Hmong Word None Hmong
DLTC F-21076S Informed Consent - Children's Long-Term Support Functional Screen - Spanish Word None Spanish
DDE-4277 F-24277 Informed Consent for Medication IF ABLE, PRINT BACK-TO-BACK PDF None English
DDE-4277 F-24277 Informed Consent for Medication IF ABLE, PRINT BACK-TO-BACK Word None English
DMHSAS F-24277_Sp Informed Consent for Medication, Spanish IF ABLE, PRINT BACK-TO-BACK PDF None Spanish
DMHSAS F-24277_Sp Informed Consent for Medication, Spanish IF ABLE, PRINT BACK-TO-BACK Word None Spanish
DDE-0941 F-20941 Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration Word None English
DDE-0941 F-20941 Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration (PDF, 30 KB) PDF None English
DDE-0941 F-20941S Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration - Spanish Word None Spanish
DDE-0941 F-20941S Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration - Spanish (PDF, 32 KB) PDF None Spanish
DDE-0941A F-20941A Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration--For Counties Converting to Managed Care (PDF, 39 KB) PDF None English
DDE-4277 BRD F-24277 BRD Informed Consents for Medications: Brand Name Index IF ABLE, PRINT BACK-TO-BACK Word None English
DDE-4277 GEN F-24277 GEN Informed Consents for Medications: Generic Name Index IF ABLE, PRINT BACK-TO-BACK Word None English
DLTC F-01350 Initial/Recertification Service Plan Checklist (Model) (PDF, 27 KB) PDF None English
DPH-45030 F-45030 Inspection Narrative Paper Form Center English
DPH-04750 F-44750 Inspection Report - Supplement (PDF, 38 KB) PDF Form Center English
OQA-2461I F-62461i Instructions - Application For Critical Access Hospital Certification Of Approval Paper Program English
DLTC F-00950i Instructions - CMS 10003-NDMCP, Notice of Denial of Medical Coverage Word None English
DMHSAS F-21276AI Instructions - CST Initiative 2015 Statewide Expansion Application (PDF, 92 KB) PDF None English
DDE-0445I F-20445i Instructions - Individual Service Plan - Medicaid Waivers (PDF, 34 KB) PDF None English
DMT-0855A F-80855A Instructions for Completing Expenditure Report - F-80855 (PDF, 14 KB) PDF None English
DMT-0862A F-80862A Instructions for Completing Expenditure Report - F-80862 (PDF, 14 KB) PDF None English
DES F-80983AS Instructions for Completing the Civil Rights Complaint Form (PDF, 20 KB) PDF None Spanish
DLTC F-00989i Instructions for Completing Wisconsin’s Individualized Family Service Plan (IFSP) (PDF, 262 KB) PDF None English
OQA-2022A F-62022A Instructions for Report of Hours Worked and Resident Census Forms Word None English
OQA 2022A F-62022A Instructions for Report of Hours Worked and Resident Census Forms (PDF, 62 KB) PDF None English
DPH-45029I F-45029i Instructions For School Food Safety Plan Paper Form Center English
DLTC F-00232i Instructions for Using the Notice of Action (F-00232) (PDF, 177 KB) PDF None English
DPH-04118 F-44118 Instructions For WIC Vendor Application Word Program English
DPH-04118A F-44118A Instructions For WIC Vendor Application Word Program English
DDE-9315 F-29315 Instructions: Declaration of Income and Assets and State Residency (PDF, 50 KB) PDF None English
DMHSAS F-00880 Intent to Provide Comprehensive Community Services (CCS) on a Regional Basis Word None English
DDE-2637 F-22637 Interagency Notification -Termination of Community Waiver Participation (PDF, 18 KB) PDF None English
HCF-10142 F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF, 107 KB) PDF None English
DPH-42010 F-42010 Interjurisdictional Tuberculosis Notification (PDF, 24 KB) PDF None English
DPH-42011 F-42011 Interjurisdictional Tuberculosis Notification - Follow-up (PDF, 87 KB) PDF None English
EXEC F-83271 Internet Site Evaluation System None English
DLTC F-01286a Intial and Final Transition Plans - Instructions (PDF, 128 KB) PDF None English
DDE-0891 F-20891 Intoxicated Driver Program Supplemental Funding Request Word None English
DMT-0138 F-80138 Invoice / Credit Memo Input Excel None English
DMT-0138A F-80138A Invoice / Credit Memo Input Supplement Excel None English
DMT-0138I F-80138i Invoice Credit Memo Input Instructions Word None English
DMT-0921 F-80921 Invoice Request - Print on Buff Paper Word None English
DMT-0921B F-80921B Invoice Request - Supplement Print on BUFF Paper Word None English
DMT-0921A F-80921A Invoice Request Instructions 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-01217A IRIS Advisory Committee Application Word None English
DLTC F-01210A IRIS Budget Amendment Provider Quote Comparison Word None English
DLTC F-01210 IRIS Budget Amendment Request Word None English
DLTC F-01209 IRIS Certification Acknowledgment Word None English
DLTC F-01208 IRIS Consultant Agency Quality Management Plan Word None English
DLTC F-01240 IRIS Critical Incident Reconciliation Word None English
DLTC F-01201C IRIS Employer/Employee Agreement Word None English
DLTC F-01207 IRIS Fiscal Employer Agent Quality Management Plan Word None English
DLTC F-01319 IRIS Involuntary Disenrollment Request Word None English
DLTC F-01262 IRIS Involuntary Disenrollment Request - Fraud Word None English
DLTC F-01206 IRIS One-Time Expense Request Word None English
DLTC F-01206B IRIS One-Time Expense Request - Ramp Word None English
DLTC F-01206A IRIS One-Time Expense Vendor Bid Comparison Word None English
DLTC F-01205E IRIS Participant Education - Program Integrity - Budget Monitoring Word None English
DLTC F-01205D IRIS Participant Education - Program Integrity - Program Integrity 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-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-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-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-01205 IRIS Participant Education—Self-Direction Responsibilities Word None English
DLTC F-01205H IRIS Participant Education—Self-Direction Responsibilities, Hmong Word None Hmong
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-01201A IRIS Participant-Hired Worker Relationship Identification Word None English
DLTC F-01308 IRIS Program Annual Review Checklist Word None English
DLTC F-01310A IRIS Program Conflict of Interest Disclosure - Participant Word None English
DLTC F-01310 IRIS Program Conflict of Interest Disclosure – Provider Word None English
DLTC F-01200 IRIS Program Cost Share Repayment Agreement Word None English
DLTC F-01314 IRIS Program Employment Checklist Word None English
DLTC F-01204 IRIS Program Notice of Action Word None English
DLTC F-01309 IRIS Program Orientation and Enrollment Checklist Word None English
DLTC F-01312 IRIS Provider Application Word None English
DLTC F-01275 IRIS Provider Board Member Disclosure Word None English
DLTC F-01203 IRIS Provider Education—Health and Safety – Incident Reporting Word None English
DLTC F-01201 IRIS Provider Education—Hired Worker Employee Set-Up Word None English
DLTC F-01258 IRIS Self - Directed Personal Care (SDPC) Disclosure Statement Word None English
DLTC F-01201B IRIS Supportive Home Care/Self-Directed Personal Care/Respite Care Training Verification Word 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
DMT-0122 F-80122 Journal Voucher Excel None English
DMT-0122A F-80122A Journal Voucher Supplement Excel None English
OQA-9307 F-69307 Kitchen / Food Service Observation HCFA-804 Paper Form Center English
DES F-00042 Knowledge Journal Word None English
DPH-07461D F-47461D Label-Prewash Paper Program English
DPH-07461B F-47461B Label-Rinse Paper Program English
DPH-07461C F-47461C Label-Sanatize Paper Program English
DPH-07461A F-47461A Label-Wash Paper Program English
HCF-01130 F-01130 Laboratories Terms of Reimbursement (PDF, 42 KB) PDF None English
OQA-2501 F-62501 Laboratory Application for Approval to Perform Alcohol Tests Word None English
OQA-2501 F-62501 Laboratory Application for Approval to Perform Alcohol Tests (PDF, 62 KB) PDF None English
DPH F-44063 Lead (Pb) Principal Instructor Application (PDF, 50 KB) PDF None English
DPH-44015 F-44015 Lead Abatement Worker - General Supervision Qualification Affidavit (PDF, 19 KB) PDF None English
  F-01320 Lead Test Kit Documentation Word Program English
DPH-44013 F-44013 Lead-Based Paint (LBP) Investigation Summary Report (PDF, 218 KB) PDF None English
DPH F-00171 Lead-Based Paint Activities & Investigations Certification Application - Company (PDF, 25 KB) PDF None English
DPH-44010 F-44010 Lead-Free / Lead-Safe Property Registry, Training Course, Class and Roster Database Access Application (PDF, 16 KB) PDF None English
DPH-44014 F-44014 Lead-Free Inspection Affidavit of Property Owner (PDF, 119 KB) PDF None English
DPH-04001H F-44001H Legal Notice (Required Immunizations for Admission to Wisconsin Schools - Hmong (PDF, 29 KB) PDF None Hmong
DPH-04001 F-44001 Legal Notice (Required Immunizations for Admission to Wisconsin Schools) (PDF, 38 KB) PDF None English
DPH-04001S F-44001S Legal Notice (Required Immunizations for Admission to Wisconsin Schools) - Spanish (PDF, 152, KB) PDF None Spanish
DDE-6003 F-26003 Letter - Notice of Privacy Practices - Treatment Facilities - HCC Word None English
DDE-6003 F-26003 Letter - Notice of Privacy Practices - Treatment Facilities - HCC (PDF, 80 KB) PDF None English
DDE-6003S F-26003S Letter - Notice of Privacy Practices - Treatment Facilities - HCC, Spanish Word None Spanish
DDE-6003S F-26003S Letter - Notice of Privacy Practices - Treatment Facilities - HCC, Spanish (PDF, 83 KB) PDF None Spanish
DDE-6003 F-26003A Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC Word None English
DDE-6003 F-26003A Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC (PDF, 78 KB) PDF None English
DDE-6003 F-26003AS Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC, Spanish Word None Spanish
DDE-6003 F-26003AS Letter - Notice of Privacy Practices - Treatment Facilities - NON HCC, Spanish (PDF, 81 KB) PDF None Spanish
DDE-6003H F-26003H Letter - Notice of Privacy Practices – Treatment Facilities - HCC, Hmong (PDF, 90 KB) PDF None Hmong
DDE-6003H F-26003AH Letter - Notice of Privacy Practices – Treatment Facilities - NON-HCC, Hmong (PDF, 60 KB) PDF None Hmong
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
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
OQA-2019 F-62019 License Application - Nursing Home, Facility for the Developmentally Disabled or Institute for Mental Disease Word None English
OQA-2019 F-62019 License Application - Nursing Home, Facility for the Developmentally Disabled or Institute for Mental Disease (PDF, 106 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
DPH-45032 F-45032 License, Permit or Registration - Radiation Only Paper Program English
HCF-10144 F-10144 Life Insurance Inquiry Word None English
DMT-0911 F-80911 Limited Term (LTE) Employment or Project Employment Application Word None English
DMT-0911A F-80911A Limited Term (LTE) Employment or Project Employment Application Instructions (PDF, 15 KB) PDF None English
DMT-0911 F-80911 Limited Term Employment or Project Employment Application (PDF, 47 KB) PDF None English
DMT-0891 F-80891 List of Expected Contracts Excel None English
DMT-0891A F-80891A List of Expected Contracts - Instructions (PDF, 24 KB) PDF None English
OQA-2155A F-62155i Living Unit Census and Direct Care Staff Reports Instructions (PDF, 51 KB) PDF None English
OQA-2155 F-62155 Living Unit Census Report Word None English
DQA F-62155 Living Unit Census Report (PDF, 19 KB) PDF None English
OQA-2156 F-62156 Living Unit Direct Care Staff Report - Day Shift Word None English
OQA-2157 F-62157 Living Unit Direct Care Staff Report - Evening Shift Word None English
OQA-2158 F-62158 Living Unit Direct Care Staff Report - Night Shift Word None English
DQA F-62156 Living Unit Direct Care Staffing Report - Day Shift (PDF, 14 KB) PDF None English
DQA F-62157 Living Unit Direct Care Staffing Report - Evening Shift (PDF, 13 KB) PDF None English
DQA F-62158 Living Unit Direct Care Staffing Report - Night Shift (PDF, 13 KB) PDF None English
HCF-16104 F-16104H Local Agency Customer Feedback (Hmong) (PDF, 55 KB) PDF None English
HCF-16104 F-16104 Local Agency Customer Feedback (PDF, 129 KB) Paper Form Center English
HCF-16104S F-16104S Local Agency Customer Feedback - Spanish (PDF, 29 KB) Paper Form Center Spanish
OQA-9259 F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671 Paper Form Center English
DQA F-62595 Long Term Care Facility Feeding Assistant Roster Word None English
DQA F-62595 Long Term Care Facility Feeding Assistant Roster (PDF, 11 KB) PDF None English
DPH-42007 F-42007 Mail Label 3 X 4 - Immunization Program Paper Program English
DPH-04828 F-44828 Make Your Smile Count - Oral Screening Paper Form Center English
HCF-12029 F-12029 Managed Care Disenrollment Request Paper Program English
DDE-2683 F-22683 MAPT Time Study Excel None English
DLTC F-00777 MAPT Vendor Related Allocation Formula Word None English
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
DLTC F-00152 MCO Request to Pay Over the Medicaid Fee-for-Service Reimbursement Rate Word None English
HCF-10191 F-10191 Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) PDF None English
HCF-10126 F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) PDF None English
HCF-10126H F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) PDF None Hmong
HCF-10126S F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) PDF None Spanish
HCF-10129 F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) PDF None English
HCF-10129H F-10129H Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) PDF None Hmong
HCF-10110 F-10110 Medicaid / BadgerCare Plus Certification System None English
HCF-10110 F-10110A Medicaid / BadgerCare Plus Certification Instructions System None English
HCF-10151 F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) PDF None English
HCF-10109 F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) PDF None English
HCF-13175 F-13175 Medicaid / Family Care / Partnership / BadgerCare Plus / (PDF, 24 KB) Estate Recovery Notification of Death (PDF, 24 KB) PDF None English
HCF-10093S F-10093S Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) PDF None Spanish
HCF-10093 F-10093 Medicaid and BadgerCare Plus Overpayment Notice Word None English
HCF-10093 F-10093 Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) PDF None English
HCF-10093 F-10093S Medicaid and BadgerCare Plus Overpayment Notice - Spanish Word None English
HCF-10192 F-10192 Medicaid Annuity Information - Disclosure (PDF, 2.1 MB) PDF None English
HCF-10095 F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (PDF, 395 KB) PDF None English
HCF-10095S F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish (PDF, 35 KB) PDF None Spanish
HCF-10137 F-10137 Medicaid Change Report (PDF, 88 KB) Paper Form Center English
HCF-10137H F-10137H Medicaid Change Report - Hmong (PDF, 98 KB) PDF None Hmong
HCF-10137S F-10137S Medicaid Change Report - Spanish (PDF, 65 KB) PDF None Spanish
DDE-1042 F-21042 Medicaid Denial Chart Word None English
DDE-1042 F-21042 Medicaid Denial Chart (PDF, 16 KB) PDF None English
HCF-10112 F-10112 Medicaid Disability Application (PDF, 1982 KB) Paper Form Center English
HCF-10112S F-10112S Medicaid Disability Application - Spanish (PDF, 275 KB) PDF None Spanish
HCF-10114 F-10114 Medicaid Disability Redetermination Report (PDF, 222 KB) PDF None English
HCF-10187 F-10187 Medicaid Divestment Penalty and Undue Hardship Notice Word None English
HCF-10097 F-10097 Medicaid Income Allocation Notice (PDF, 44 KB) PDF None English
HCF-10097S F-10097S Medicaid Income Allocation Notice - Spanish (PDF, 49 KB) PDF None Spanish
HCF-10190 F-10190 Medicaid Issuer of Annuity - Notice of Obligation (PDF, 641 KB) PDF None English
HCF-10108 F-10108 Medicaid Manual Notice for Cost of Care Contribution (PDF, 168 KB) PDF None English
HCF-10108A F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions (PDF, 509 KB) PDF None English
HCF-10098 F-10098 Medicaid Member Asset Allocation Notice (PDF, 85 KB) PDF None English
HCF-10098S F-10098S Medicaid Member Asset Allocation Notice - Spanish (PDF, 39 KB) PDF None Spanish
HCF-10130 F-10130 Medicaid Presumptive Disability (PDF, 51 KB) PDF None English
DQA F-00309 Medicaid Provider Report Word None English
DQA F-00309 Medicaid Provider Report (PDF, 65 KB) PDF None English
HCF-10127 F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) PDF None English
HCF-10121 F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration (PDF, 29 KB) PDF None English
HCF-10122 F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information (PDF, 117 KB) PDF None English
HCF-13024 F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions (PDF, 1.4 MB) PDF None English
HCF-13023 F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions (PDF, 1.3 MB) PDF None English
DHCAA F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) PDF None English
HCF-10106S F-10106S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice - Spanish (PDF, 124 KB) PDF None Spanish
HCF-10106 F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice (PDF, 342 KB) PDF None English
HCF-10107 F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice (PDF, 477 KB) PDF None English
HCF-10107S F-10107S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice - Spanish (PDF, 54 KB) PDF None Spanish
HCF-10189 F-10189 Medicaid Undue Hardship Bedhold Notice Word None English
HCF-10193 F-10193 Medicaid Undue Hardship Request (PDF, 2.7 MB) PDF None English
HCF-10188 F-10188 Medicaid Undue Hardship Waiver Decision Word None English
DDE-0919 F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet Word None English
DDE-0919 F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet (PDF, 40 KB) PDF None English
DDE-0810 F-20810 Medicaid Waiver Program Health Report Word None English
DDE-0810 F-20810 Medicaid Waiver Program Health Report (PDF, 52 KB) PDF None English
HCF-10129S F-10129S Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) PDF None Spanish
DLTC F-00295 Medical and Remedial Expenses Checklist - Update Word None English
HCF-01506 F-01506 Medical Supply and Equipment Vendor Terms of Reimbursement (PDF, 34 KB) PDF None English
CMS-677 F-69265 Medication Administration Observation CMS-20056 Paper Form Center 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
DLTC F-00942 Meet our "Henry" Word None English
HCF-01507 F-01507 Mental Health / Substance Abuse Services Terms of Reimbursement (PDF, 61 KB) PDF None English
DQA F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 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-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 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-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 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-00657 Military Training Verification Word None English
DQA F-00657 Military Training Verification (PDF, 24 KB) PDF None English
OQA-2674A F-62674A Model Balance Sheet Word None English
OQA-2674A F-62674A Model Balance Sheet (PDF, 29 KB) PDF None English
DLTC F-00334 Money Follows the Person (MFP) - Participant Reporting Word None English
DLTC F-00334 Money Follows the Person (MFP) - Participant Reporting (PDF, 57 KB) PDF None English
DLTC F-01282 Monthly Enrollment Discrepancy Report Template-Model Excel None English
DPH-40073 F-40073 Monthly Physical Activity Sheet (PDF, 61 KB) PDF None English
DPH-07029 F-47029 Monthly Swimming Pool Operation Report (PDF, 86 KB) PDF None English