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-82069 | Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities | DQA | None |
| F-02296 | Medicaid Fraud Control Elder Abuse Unit Referral | OIG | None |
| F-10101 | Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet | DMS | Other |
| F-10095 | Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse | DMS | None |
| F-10097 | Medicaid Income Allocation Notice | DMS | None |
| F-40065 | The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report | DPH | None |
| F-10144 | Wisconsin Life Insurance Inquiry | DMS | None |
| F-01389 | ROSI Adult Satisfaction Survey | DCTS | None |
| F-01389A | MHSIP Youth Satisfaction Survey | DCTS | None |
| F-01389B | MHSIP Family Satisfaction Survey | DCTS | None |
| F-00052 | Aging and Disability Resource Center (ADRC) Application | DPH | None |
| F-01219-pckt | WISEWOMAN Integrated Office Visit Assessment Packet | DPH | None |
| F-01221 | WISEWOMAN Screening Activity | DPH | None |
| F-22540 | Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs | OPIB | None |
| F-22540A | Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet | OS | None |
| F-44243 | Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report | DPH | Other |
| F-04020L | Student Immunization Record, Long | DPH | None |
| F-80881 | Profile ID Request (CARS) | DES | None |
| F-00476 | CARES Automated Systems Access Request | DMS | None |
| F-20891 | Intoxicated Driver Program Supplemental Funding Request | DCTS | None |
| F-02314A | Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees | DPH | None |
| F-02559 | Assistive Technology Survey for MCO and ICA Staff | DMS | None |
| F-02560 | Assistive Technology Survey for Members, Participants, and Providers of Medicaid-Funded Long-Term Care Programs | DMS | None |
| F-40062 | TEFAP / CSFP Commodity Loss Report | DPH | None |
| F-20445 | Individual Service Plan – Children’s Long-Term Support Programs | DMS | None |
| F-40034 | Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing | DPH | None |
| F-44763 | Emergency Care Do Not Resuscitate Order (DNR) | DPH | None |
| F-00123 | Wisconsin Declaration of Domestic Partnership Application | DPH | None |
| F-40063 | TEFAP / CSFP Commodities Complaint | DPH | None |
| F-40064 | Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs | DPH | None |
| F-40098 | Worksite Wellness Kit Survey and Request | DPH | None |
| F-20445A | Individual Service Plan - Outcomes - Children’s Long-Term Support Programs | DMS | None |
| F-10112 | Medicaid Disability Application | DMS | Other |
| F-00653 | Importing Procedure Records in NHSN (SSI DENOMINATOR) | DPH | None |
| F-00024 | HSRS Core Summary Report | OS | None |
| F-80477A | Canteen Operations Analysis of Cash - GAAP Basis | DES | None |
| F-10182 | BadgerCare Plus Application Packet | DMS | Other |
| F-44001 | Legal Notice: Required Immunizations for Admission to Wisconsin Schools | DPH | None |
| F-04003 | Vendor Monitoring Worksheet: Wisconsin WIC Program | DPH | None |
| F-02558 | Family Care Member Out-of-County Notification | DMS | None |
| F-40059 | The Emergency Food Assistance Program (TEFAP) Eligibility Certification | DPH | None |
| F-40019 | Affirmation of Identity, Residency, and/or Income | DPH | None |
| F-02476A | Nurse Aide Federal Employment Eligibility Renewal: Employee Roster | DQA | None |
| F-40096 | eWIC Program Repayment Agreement | DPH | None |
| F-82009II | WIC Confidential Information Release Authorization | DPH | Other |
| F-02040 | WIC Program Notice of Categorical Ineligibility | DPH | None |
| F-44161A | WIC Cardholder Rights and Responsibilities | DPH | None |
| F-45006 | Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices | DPH | None |
| F-45013 | Application for a Radioactive Material License Authorizing the Use of Industrial Radiography | DPH | None |
| F-02011 | Fluoride Mouth Rinse Program Annual Report | DPH | None |
Pages
Last Revised: March 26, 2019
