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-02541 Wisconsin Birth Defects Condition Nomination DPH
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral OIG
F-16019B FoodShare Wisconsin Registration Packet DMS
F-29315 Declaration of Income and Assets, and State Residency Instructions DMS
F-16028 Notice of FoodShare Overissuance DMS
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys DCTS
F-29314 COP Declaration of Income and Assets, and State Residency DPH
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-44764 Do Not Resuscitate Bracelet - Electronic Format DPH
F-02314E Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation for Annual Employee Screening DPH
F-00330 Request for Replacement FoodShare Benefits DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments DPH
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-16019A FoodShare Wisconsin Registration DMS
F-40085 WIC Program Notice of Ineligibility DPH
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-10182 BadgerCare Plus Application Packet DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs DPH
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement DPH
F-40310 Adult Oral Health Screening DPH
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site DMS
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy DPH
F-62610 Nurse Aide Training Program Primary Instructor Application DQA
F-62687 Nurse Aide Training Program - Trainer Application DQA
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) DMS
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) DMS
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation DPH
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-04020L Student Immunization Record, Long DPH
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-02388 MIPPA Grant Agency Application DPH
F-00923 Reschedule Lead (PB) Certification Exam DPH
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information DMS
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-02558 Family Care Member Out-of-County Notification DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-47255 Emergency Medical Services Program Municipal Signature and Population Verification DPH
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) DPH
F-02466 MCO Appeal Log for Family Care, Family Care Partnership, and PACE Programs DMS
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) DPH
F-02431 Statement About U.S. Military Service DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36 DQA

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Last Revised: March 26, 2019