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-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-62680 Home Health Agency (HHA): Clinical Record Review (State Only) DQA
F-62062 Hospice License Application DQA
F-62680A Home Health Agency (HHA): Clinical Record Review (State & Federal) DQA
F-62231 Home Health Agency Personnel Record Review DQA
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-16019B FoodShare Wisconsin Registration Packet DMS
F-16026 Prosecution Diversion Agreement DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-62674 Home Health Agency License Application DQA
F-02577 Proof of In-Kind Hours DMS
F-02603 Request for a Temporary Waiver of MAPP Premium DMS
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-00036 Power of Attorney for Finance and Property DPH
F-44161 WIC Rights and Responsibilities DPH
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-80025 Forms / Publications Order OS
F-16028 Notice of FoodShare Overissuance DMS
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-04002 School Report to Local Health Department DPH
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-16024 FoodShare Notice of Disqualification DMS
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-10114 Medicaid Disability Redetermination Report DMS
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-40085 WIC Program Notice of Ineligibility DPH
F-16025 Disqualification Consent Agreement DMS
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement DMS
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-16019A FoodShare Wisconsin Registration DMS
F-02491 FoodShare Buy and Make Food Separately DMS
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training DPH
F-19002 Request to Reduce QUEST Card Balance DMS
F-01542 Notification of Required Drug Testing DMS
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS
F-40096 eWIC Program Repayment Agreement DPH
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-40028 Participant Determination Letter DPH
F-00330 Request for Replacement FoodShare Benefits DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-00805 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents DMS


Last Revised: March 26, 2019