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-02390 Fall Medicare Training Participant Survey DPH
F-02721 Notice of Adverse Benefit Determination DPH
F-00236A Request for a State Fair Hearing - ADRC DPH
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-02743 Application Telecommunications Assistance Program Hearing Aid Assistance (TAP HAA) DPH
F-44019A Immunization Assessment DPH
F-00004 Health and Employment Counseling Application DMS
F-44126 Antituberculosis Therapy Program Medication Refill Request DPH
F-02306 Application for Telecommunication Assistance Program (TAP) DPH
F-02763 Acute Hospital Care at Home Program: Emergency Request for Approval DQA
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-00950 Partnership Coverage Decision Letter DMS
F-02759 Comprehensive Community Services Cost Settlement Advance Request DMS
F-19002 Request to Reduce QUEST Card Balance DMS
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA
F-02749 Support (CLTS) Exceptional Expense Notification DMS
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-02656 Federally Qualified Health Center Cost Report DMS
F-11129A Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions DMS
F-11129B-H Tribal and Out-of-State Federally Qualified Health Center Cost Report Forms OIG
F-11130 Tribal and Out-of-State Federally Qualified Health Center Interim Report DMS
F-02758 Federally Qualified Health Center Outstationed Enrollment Survey OIG
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions DPH
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-00805 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-01430 Prior Authorization Drug Attachment for Xyrem and Xywav DMS
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-00888 ADRC Action Plan DPH
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-21353 Children's Long-Term Support Waiver High-Cost Request DMS
F-00401 Preferred Drug List Expedited Emergency Supply Request DMS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP) DPH
F-02476 Nurse Aide Federal Employment Eligibility Renewal Waiver Request DQA
F02761 Health Care Entity Staffing Request DPH
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS
F-02721B Notice of Medical Remedial Expenses DPH
F-02721A Notice of Delay in Functional Eligibility Determination DPH
F-20582 Medicaid – Katie Beckett Program Application DMS
F-02746 Request for Institution of Mental Disease Determination for Residential Substance Use Disorder Facilities DMS
F-02067 Women, Infants, and Children (WIC) Staff Training Record DPH
F-40019 Affirmation of Identity, Residency, Income, or Benefit Loss DPH
F-10150A Your Rights and Responsibilities for Health Care DMS
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-44621 WIC Stock Price Survey DPH
F-02140 Urgent Services Agreement DPH
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH

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Last Revised: March 26, 2019