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
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement
F-00004A Health and Employment Counseling - I Think I Need More Time
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-00004B Health and Employment Counseling - I Have Reached Employment
F-01781 Immunization Program Functional Exercise 2018-2019 (BP1 Supplemental)
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center
F-00237SO Appeal Request - MCOs, Somali
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint
F-04002 School Report to Local Health Department
F-00004 Health and Employment Counseling Application
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint
F-02108 Adult Family Home
F-22538 Consent to Film or Tape
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement
F-04020L Student Immunization Record, Long
F-01601A CST Summary Line Item Budget
F-16019A FoodShare Wisconsin Registration
F-01999B 2019 Senior Companion Program: State Match Funding Application
F-01999 2019 Foster Grandparent Program: State Match Funding Application
F-01999A 2019 Retired Senior Volunteer Program: State Match Funding Application
F-02369 Certification of Need for Laboratory Services
F-00476 CARES Automated Systems Access Request
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification
F-10137 Medicaid Change Report
F-00076 Variance Request - WaitList
F-02191 CLTS County Waitlist Transition Plan
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist
F-00657 Nurse Aide Training Program: Military Training Verification
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers
F-19002 Request to Reduce QUEST Card Balance
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-16026 Prosecution Diversion Agreement
F-10150A Your Rights and Responsibilities for Health Care
F-00596 PPS Mental Health Module
F-00596a PPS Mental Health Deskcard
F-00588 PPS Alcohol and Other Drug Abuse Module
F-01205P IRIS Participant Education: Background Check Process
F-01261 Fraud Statement - IRIS Program
F-01205M IRIS Participant Education: Restrictive Measures
F-62696 Student Nurse / Graduate Nurse Verification
F-82064 Background Information Disclosure (BID)
F-01205A IRIS Participant Education: Health and Safety - Incident Reporting
F-01205K IRIS Participant Education: Annual Health Care Information
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-01205B IRIS Participant Education: Budget Amendments

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Last Revised: May 22, 2018