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-00052C Organizational Transition for Dementia Care Specialist DPH
F-20985 Participant Rights and Responsibilities Notification DMS
F-01697 Application for Farmers Market or Direct Marketing Farmer EBT FoodShare Payment Processing Equipment DMS
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS
F-01578A IRIS SharePoint - Request for User Setup DMS
F-02069 DHS Quarterly Report on Consumers Enrolled in CCS DCTS
F-02721 Notice of Adverse Benefit Determination DPH
F-02721A Notice of Delay in Functional Eligibility Determination DPH
F-02721B Notice of Medical Remedial Expenses DPH
F-02331 Caregiver Programs Customer Satisfaction Survey DPH
F-02658 COVID-19 Testing DQA
F-02306 Application for Telecommunication Assistance Program (TAP) DPH
F-80112 Vendor Validation DES
F-10112A Medicaid – Disability Application Addendum DMS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-02741 Wisconsin Emergency Assistance Volunteer Registry (WEAVR): COVID-19 Staffing Request DPH
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS
F-02595 Request for Approval: Youth Crisis Stabilization Facilities (YCSF) Certification Application DCTS
F-02737 COVID Impact Survey for Behavioral Health Providers – Prep DCTS
F-00004 Health and Employment Counseling Application DMS
F-02738 Family Care Partnership Appeal Decision Letter DMS
F-02739 Family Care Partnership Letter about Your Right to Make a Fast Complaint DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-02461 Tuberculosis (TB) Treatment Assistance Program - Special Request DPH
F-02734 Nursing Home Notification of Intent to Use Asymptomatic, COVID Positive Staff DQA
F-04002 School Report to Local Health Department DPH
F-49357 Personal Diabetes Care Record DPH
F-21343 Alzheimer's Family and Caregiver Support Program (AFCSP) Budget Report DPH
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-02720 Family Caregiver Support Program Evaluation DPH
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-82009 Confidential Information Release Authorization - Generic  DES
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement DMS
F-02651 Nursing Home: COVID-19 Change Worksheet DQA
F-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet DMS
F-02605A HCBS Settings Rule: Heightened Scrutiny Settings Review – Evidentiary Document Checklist DMS
F-02389 Fall Medicare Training for Wisconsin Professionals DPH
F-02725 Application for COVID Connect Collection Site OS
F-02726 Hand Hygiene (HH) and Personal Protective Equipment (PPE) Observations DPH
F-02530 Application for Wisconsin's Test of English Proficiency (TEP) and Board for Examination of Interpreters (BEI) DPH
F-01203 IRIS Provider Education – Health and Safety – Incident Reporting DMS
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) DMS
F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook DCTS
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook DCTS
P-01391 Mental Health Statistics Improvement Program (MHSIP) Adult Data Workbook DCTS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-62333 Plan Approval Application and Instructions DQA
F-02715 ADRC Client Tracking System Waiver Request DPH
F-02714 ADRC Professional Training Participant Survey DPH


Last Revised: March 26, 2019