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 Other Location Language
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement English
F-10075 Wisconsin Well Woman Medicaid Application and Renewal English
F-00036 Power of Attorney for Finance and Property English
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup English
F-02250 Quarterly Program Integrity Report English
F-01578A IRIS SharePoint - Request for User Setup English
F-00388 County Birth to 3 Fiscal Reconciliation Report English
F-16030 FoodShare Wisconsin Under/Overissuance Worksheet and Overpayment Calculator English
F-01744 Vaccine Restitution Policy - Agreement English
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request English
F-11008 Prior Authorization / Therapy Attachment (PA/TA) English
F-44017 Asbestos Application - Individual English
F-02257 Temperature Excursion Incident Report - WIsconsin Vaccines for Children Program (VFC) English
F-00166 Service Delivery Discrimination Complaint English
F-01468 IRIS Program Start Date Letter – New Participant English
F-00543A File Review Checklist English
F-00989L Summary of Services (IFSP) English
F-02047 IRIS Financial Reporting Template English
F-80881 Profile ID Request (CARS) English
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis English
F-00913 Annual Survey of Nursing Homes English
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger English
F-01952 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Giant Cell Arteritis, and Neonatal Onset Multisystem Inflammatory Disease (NOMID) English
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-steroidal Anti-Inflammatory Drugs (NSAIDs) English
F-00079 Prior Authorization Drug Attachment for Modafinil and Nuvigil® English
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine English
F-11304 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis English
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents English
F-01950 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis English
F-11306 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis English
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs English
F-44192 Child Care Immunization Record English
F-80025 Forms / Publications Order English
F-00615A Change Project Summary and Instructions English
F-00615 Change Project Report and Instructions English
F-00366 Wisconsin Adult Long-Term Care Functional Screen English
F-20582 Medicaid – Katie Beckett Program Application and Recertification English
F-02022 Claims Audit Report for Managed Long-Term Care MCOs English
F-44215 Child Care Center Report to the District Attorney English
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers English
F-02260 Temporary QUEST Card Issuance Checklist English
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet English
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer English
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals English
F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents Renewal English
F-01210 IRIS Budget Amendment Request English
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization English
F-62233 Hospice Personnel Record Review English
F-01736 Vaccine Return - Request for Authorization to Return English
F-44746 Farmers Market Nutrition Program (FMNP) - Site Observation Worksheet English

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Last Revised: July 28, 2017