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.
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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-11051 | Prior Authorization / Vision Services Attachment (PA/VA) | DMS | None |
| F-62680 | Home Health Agency (HHA): Clinical Record Review (State Only) | DQA | None |
| F-62062 | Hospice License Application | DQA | None |
| F-62680A | Home Health Agency (HHA): Clinical Record Review (State & Federal) | DQA | None |
| F-62231 | Home Health Agency Personnel Record Review | DQA | None |
| F-10126 | Appoint, Change, or Remove an Authorized Representative | DMS | None |
| F-16019B | FoodShare Wisconsin Registration Packet | DMS | Other |
| F-16026 | Prosecution Diversion Agreement | DMS | None |
| F-16066 | FoodShare Wisconsin Income Change Report | DMS | None |
| F-62674 | Home Health Agency License Application | DQA | None |
| F-02577 | Proof of In-Kind Hours | DMS | None |
| F-02603 | Request for a Temporary Waiver of MAPP Premium | DMS | None |
| F-10127 | Medicaid Purchase Plan (MAPP) - Work Requirement Exemption | DMS | None |
| F-00036 | Power of Attorney for Finance and Property | DPH | None |
| F-44161 | WIC Rights and Responsibilities | DPH | Other |
| F-02527 | Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) | DQA | None |
| F-80025 | Forms / Publications Order | OS | None |
| F-16028 | Notice of FoodShare Overissuance | DMS | None |
| F-10121 | Medicaid Purchase Plan (MAPP) Independence Account Registration | DMS | None |
| F-16038 | Administrative Disqualification Hearing Notice | DMS | None |
| F-44161A | WIC Cardholder Rights and Responsibilities | DPH | None |
| F-16039 | Waiver of Administrative Disqualification Hearing | DMS | None |
| F-04002 | School Report to Local Health Department | DPH | None |
| F-40076 | Women, Infants, and Children (WIC) Nutrition Program Employer Statement | DPH | None |
| F-16024 | FoodShare Notice of Disqualification | DMS | None |
| F-40036 | Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor | DPH | None |
| F-10114 | Medicaid Disability Redetermination Report | DMS | None |
| F-02040 | WIC Program Notice of Categorical Ineligibility | DPH | None |
| F-40085 | WIC Program Notice of Ineligibility | DPH | None |
| F-16025 | Disqualification Consent Agreement | DMS | None |
| F-00136 | FoodShare Employment and Training (FSET) Program Participation Agreement | DMS | None |
| F-40044 | Participant Agreement, Rights & Responsibilities | DPH | Other |
| F-16019A | FoodShare Wisconsin Registration | DMS | Other |
| F-02491 | FoodShare Buy and Make Food Separately | DMS | None |
| F-40053 | Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training | DPH | None |
| F-19002 | Request to Reduce QUEST Card Balance | DMS | None |
| F-01542 | Notification of Required Drug Testing | DMS | None |
| F-40019 | Affirmation of Identity, Residency, and/or Income | DPH | None |
| F-16001 | Notice of Denial of Benefits/Negative Change in Benefits | DMS | None |
| F-10110 | Medicaid/BadgerCare Plus Eligibility Certification | DMS | None |
| F-40096 | eWIC Program Repayment Agreement | DPH | None |
| F-02340 | Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement | DMS | None |
| F-40028 | Participant Determination Letter | DPH | Other |
| F-00330 | Request for Replacement FoodShare Benefits | DMS | None |
| F-16004 | Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits | DMS | None |
| F-10101 | Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet | DMS | Other |
| F-00805 | Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators | DMS | None |
| F-01891 | New Employment Reporting – FoodShare Employment and Training (FSET) Program | DMS | None |
| F-10150 | Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare | DMS | None |
| F-01247 | Prior Authorization Drug Attachment for Hepatitis C Agents | DMS | None |
Pages
Last Revised: March 26, 2019
