Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Number Title Division Other Location
F-02067 Women, Infants, and Children (WIC) Staff Training Record DPH
F-11054 Prior Authorization / Enteral Nutrition Formula Attachment (PA/ENFA) DMS
F-02634A Adult Family Home (AFH) Initial Survey Checklist DQA
F-02634B Community-Based Residential Facility (CBRF) Initial Survey Checklist DQA
F-02634C Residential Care Apartment Complex (RCAC) Initial Survey Checklist DQA
F-02639 Time and Task Pretest DPH
F-01219-pckt WISEWOMAN Integrated Office Visit Assessment Packet DPH
F-01221 WISEWOMAN Screening Activity DPH
F-02634 Adult Day Care (ADC) Initial Survey Checklist DQA
F-01997 Children's Community Options (CCOP) Reconciliation Packet DMS
F-22541 Incident Report – IRIS DMS
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral DPH
F02637 Requesting FSIA Access During COVID-19 Health Emergency DMS
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) DMS
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) DMS
F-22567 Substance Abuse Prevention Treatment Block Grant Annual Reporting DCTS
F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo DMS
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo DMS
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00533 Partnership Programs - Enrollment DPH
F-02483 PACE Program Enrollment DPH
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-02558 Family Care Member County Notification DMS
F-00046 Family Care Program - Enrollment DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-01586 Medical Stockpile Access Request DPH
F-10162 Verification of Veterans Benefits DMS
F-02436 Testing Questionnaire (AIDS/HIV) DPH
F-02436A PrEP Questionnaire DPH
F-16019A FoodShare Wisconsin Registration DMS
F-01204A Letter – IRIS Program Notice of Action – Denial DMS
F-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-01204C Letter – IRIS Program Notice of Action – Reduction DMS
F-01204D Letter – IRIS Program Notice of Action – Termination DMS
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change DMS
F-00759 Business Associate Agreement: With Contract DES
F-01204E Letter – IRIS Program Notice of Action – Functional Eligibility DMS
F-02605 Home and Community-Based Services (HCBS) Settings Rule DMS
F-02616 Supervised Release (SR) Client Vehicle Purchase Request DCTS
F-00232 Notice of Adverse Benefit Determination (Notice of Action) DMS
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-02622 Vendor/Participant Complaint: Wisconsin WIC and Senior Farmers' Market Nutrition Program (FMNP) DPH
F-02445 REDCap Setup Request DPH
F-02530 Application for Wisconsin's Test of English Proficiency (TEP) and Board for Examination of Interpreters (BEI) DPH
F-10182 BadgerCare Plus Application Packet DMS
F-02522 Supervised Release Individual Client Summary DCTS

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Last Revised: March 26, 2019