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-45010D Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) DPH
F-45007 Certificate of Disposition of Materials DPH
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-45008 Application for Radioactive Material License for Medical Use DPH
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) DPH
F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) DPH
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-45021 Generally Licensed Device Inspection by Mail DPH
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-22541 Incident Report - Medicaid Waiver Programs DMS
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS DMS
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels DPH
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-60795 Community Based Residential Facility (CBRF) Fire Inspection DQA
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement DQA
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-62418 Adult Day Care Initial Certification Application DQA
F-13393 Trading Partner 835 Designation DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01186 Wisconsin Chronic Renal Disease Program Application DMS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-11067 Record of Actual Daily Oxygen Use DMS
F-13470 Claim Form Attachment Cover Page DMS
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application DQA
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-01170 Written Correspondence Inquiry DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services DMS
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-60945 Adult Family Home Initial Licensure Application DQA
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-01199 Optional School-Based Services Activity Medication Administration DMS

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Last Revised: March 26, 2019