Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Location
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-62333 Plan Approval Application and Instructions DQA
F-02000 ADRC/AGING/TRIBAL User System Access Request DPH
F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo DMS
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo DMS
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo DMS
F-01320 Lead Test Kit Documentation DPH
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement DMS
F-02788 Certified Narcotic Treatment Service for Opiate Addiction: Medication Unit Application DQA
F-02069 DHS Quarterly Report on Consumers Enrolled in CCS DCTS
F-21225A Program Participation System (PPS): B-3 Module DMS
F-02782 Coalition to End Social Isolation and Loneliness – Stakeholder Engagement Survey DPH
F-02610B Occupant Worksheet - Lead-Safe Homes Program Application DPH
F-02784 PASRR 30-Day Information Required for PASRR Exemption Letter Request DCTS
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-02610 Owner-Occupied Properties - Lead-Safe Homes Program Application DPH
F-01201A IRIS Participant-Hired Worker Relationship Identification DMS
F-02610A Rental Property - Lead-Safe Homes Program Application DPH
F-02573 Prior Authorization Drug Attachment for Wakix DMS
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS
F-11317 Certification Criteria for Providers Express Enrollment of Pregnant Women in BadgerCare Plus OIG
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-00978 Confirmation of Confidential Data Destruction - Wisconsin Cancer Reporting System (WCRS) DPH
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-02778 Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply CRT
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-02122 Opioid Crisis State Targeted Response Program Funding Request DCTS
F-21076 Informed Consent – Children's Long-Term Support Functional Screen DMS
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS
F-02522 Supervised Release Individual Client Summary DCTS
F-01885 Requesting State Trauma Registry Access DPH
F-01684 Community Mental Health Allocation (CMHA) Report DCTS
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-62062 Hospice License Application DQA
F-10098 Medicaid Member Asset Allocation DMS
F-10101 Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet DMS
F-00974 Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor DPH
F-00046 Family Care Program — Enrollment DPH
F-02483 PACE Program Enrollment DPH
F-02720A Family Caregiver Support Program Post Evaluation DPH
F-02720 Family Caregiver Support Program Initial Evaluation DPH
F-00533 Partnership Programs — Enrollment DPH
F-02053 ADRC Referral to Income Maintenance for Managed Long-Term Care Services DPH
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit DMS
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-00388 County Birth to 3 Fiscal Reconciliation Report DMS

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Last Revised: March 23, 2021