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 Numbersort descending Title Other Location Language
F-00113 Four Conditions for the Use of Funding in a CBRF English
F-00114 Service Director License Proxy for Individuals English
F-00115 Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument English
F-00119 Personal Care Agency Application for Approval English
F-00123 Wisconsin Declaration of Domestic Partnership Application English
F-00124 Wisconsin Termination Domestic Partnership Certificate Application English
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement English
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency English
F-00142 Prior Authorization / Drug Attachment for Synagis English
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate English
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request English
F-00154 Wisconsin Consultative Examination Inquiry English
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application English
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum English
F-00161 Caregiver Misconduct Reporting Requirements Worksheet (PDF, 48 KB) English
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source (PDF, 22 KB) English
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids English
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs English
F-00164 Civil Rights Compliance Plan English
F-00165 Civil Rights Compliance Letter of Assurance English
F-00166 Service Delivery / Employment Discrimination Complaint English
F-00167 Civil Rights Complaint Consent/Release English
F-00169 Opting Out of Local Educational Agency (LEA) Notification English
F-00171 Lead Company Application English
F-00176 Civil Money Penalty Funds Project Proposal English
F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies English
F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers English
F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports English
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals English
F-00191 Certified Outpatient Clinic Request for a Branch Office English
F-00191A Certified Outpatient Clinic Request for a School Branch Office English
F-00192 Referral / Communication Wisconsin WIC Program English
F-00193 Pediatric Referral / Communication Wisconsin WIC Program English
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids English
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program English
F-00201 Occupant Protection Plan (Checklist for Lead-Based Paint Activities) English
F-00202 Individual Service Plan - Community Recovery Services (CRS) English
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application English
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment English
F-00219 Self-Employment Income Report - Farmer English
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) English
F-00221 Family Care / IRIS Member Requested Disenrollment English
F-00221A Family Care / Partnership / PACE / IRIS - Disenrollment Routing English
F-00221B Family Care / Partnership / PACE / IRIS - Refusal to Accept Services and MCO Requested Disenrollment Routing English
F-00232 Notice of Action - MCOs English
F-00233 Renewal Summary Letter English
F-00236 Request for a State Fair Hearing - MCO English
F-00236A Request for a State Fair Hearing - ADRC English
F-00236B Request for a State Fair Hearing - IRIS English
F-00237 Appeal Request - MCOs English

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Last Revised: July 28, 2017