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-01563 IRIS Consultant Agency (ICA) Provider Change Letter
F-21353 Children's Long-Term Support Waiver High-Cost Request
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-02282 Resident Relocation Roster
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services
F-02460 OBVI Bold Lined Paper
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
F-01352 Background Check Appeal Request - IRIS Program
F-00950 Notice of Denial of Medical Coverage – Partnership
F-00588a PPS AODA Deskcard
F-00950A Notice of Denial of Medical Coverage – PACE
F-00963 Children’s Long Term Support Reconciliation Packet
F-80983 Civil Rights Complaint
F-00388 County Birth to 3 Fiscal Reconciliation Report
F-01997 Children's Community Options Reconciliation Packet
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-01204B Letter - IRIS Program Notice of Action - Limit
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-01204D Letter - IRIS Program Notice of Action - Termination
F-00366 Wisconsin Adult Long-Term Care Functional Screen
F-01204E Letter - IRIS Program Notice of Action - Functional Eligibility
F-00085 Power of Attorney for Health Care
F-42016 Authorization for Release of Confidential HIV Test Results
F-01204A Letter - IRIS Program Notice of Action - Denial
F-01468 IRIS Program Start Date Letter – New Participant
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-62646 Home Health Agency (HHA) Patient Rights Statement Review
F-62601 Rights of Home Health Agency Patients
F-02441 Wisconsin Interpreting and Transliterating Assessment (WITA) Permanent Status Request
F-20445 Individual Service Plan – Children’s Long-Term Support Programs
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports
F-00237SO Appeal Request - MCOs, Somali
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-02436 Testing Questionnaire (AIDS/HIV)
F-02306 Application for Telecommunication Assistance Program (TAP)
F-00237R Appeal Request - MCOs, Russian
F-25180 Order of Discharge Upon Expiration of Commitment
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions
F-00236 Request for a State Fair Hearing - MCO
F-00060 Declaration to Physicians (Living Will)
F-01201A IRIS Participant - Hired Worker Relationship Identification
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis

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Last Revised: May 22, 2018