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 Other Location
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S)
F-02324 Wisconsin’s American Sign Language Interpreter, SSP and CART Directory Sign-Up and/or Change Request
F-20445 Individual Service Plan - Medicaid Waivers
F-02412 BioSense Platform Organization Security and Confidentiality Policy Agreement
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-20445A Individual Service Plan – Individual Outcomes
F-02413 BioSense Platform User Security and Confidentiality Agreement
F-83271 DHS Website Feedback
F-02384 Syndromic Surveillance Data Use Application
F-01634 Workplace Wellness Grant Program Application
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist
F-00780A Options Counseling Tip Card Supplement
F-02410 Voluntary Property Checklist for Child Care Providers
F-21343 Alzheimer's Family and Caregiver Support Program (AFCSP) Budget Report
F-00905 Tuberculosis Disease - Initial Medication Request
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral
F-44000 Tuberculosis Disease Initial Request for Medication
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-47097 Application for Registration of X-Ray Devices
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator
F-02282A Resident Relocation Plan
F-05260 Letter of Non-Marriage Application
F-01933 Wisconsin EMS EMT Training Record - NCCP EMT Refresher Requirements
F-01935 WIsconsin EMS First Responder Training Record - NCCP First Responder Refresher Requirements
F-00681DDDL IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options (Large Print)
F-00681DD IRIS (Include, Respect, I Self-Direct) Four (4) Consultant Agency Options
F-10119 Temporary Enrollment for Family Planning Only Services
F-00681D IRIS (Include, Respect, I Self-Direct) Two (2) Consultant Agency Options
F-00681DL IRIS (Include, Respect, I Self-Direct) Two (2) Consultant Agency Options (Large Print)
F-00681DDDD IRIS (Include, Respect, I Self-Direct) Five (5) Consultant Agency Options
F-00681DDL IRIS (Include, Respect, I Self-Direct) Four (4) Consultant Agency Options (Large Print)
F-00681DDDDL IRIS (Include, Respect, I Self-Direct) Five (5) Consultant Agency Options (Large Print)
F-00681DDD IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options
F-62096A DQA Authority for Obtaining Provider Records Without Written Release
F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA)
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA)
F-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary
F-00166 Service Delivery Discrimination Complaint
F-25180 Order of Discharge Upon Expiration of Commitment
F-25205 Order to Transport
F-02377 Supported Decision-Making Agreement
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup
F-01999A 2020 Retired Senior Volunteer Program: State Match Funding Application
F-01999B 2020 Senior Companion Program: State Match Funding Application
F-01999 2020 Foster Grandparent Program: State Match Funding Application

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Last Revised: May 22, 2018