Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.
| Assigned Number | Title | Division | Other Location |
|---|---|---|---|
| F-02733 | Request for Community Spouse Signature | DMS | None |
| F-25206 | Petition for Capias | DCTS | None |
| F-25207 | Order Granting Capias | DCTS | None |
| F-10097A | Community-Based Long-Term Care Services Medicaid Income Allocation | DMS | None |
| F-01567 | Long-Term Care Insurance Policy – Assignment of Benefits | DMS | None |
| F-44614I | AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions | DPH | None |
| F-21334 | Encounter New User Request | DMS | None |
| F-16030 | FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator | DMS | None |
| F-13509 | Wisconsin Well Woman Program Provider Certification | OIG | None |
| F-40108 | Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program | DPH | None |
| F-44126 | Antituberculosis Therapy Program Medication Refill Request | DPH | None |
| F-00534 | Partnership Member Requested Disenrollment or Transfer and Instructions | DPH | None |
| F-02764 | Participant Fiscal Employer Agent (FEA) – Transfer Request | DPH | None |
| F-00075 | IRIS (Include, Respect, I Self-Direct) Authorization | DPH | None |
| F-02404 | Family Care, Partnership, PACE, or IRIS Change Routing Instructions | DPH | None |
| F-02484 | Pace Program Member Requested Disenrollment or Transfer Instructions | DPH | None |
| F-00221 | Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions | DPH | None |
| F-16019A | FoodShare Wisconsin Registration | DMS | Other |
| F-02717 | Electronic Visit Verification (EVV) Live-in Worker Identification | DMS | None |
| F-02022 | Claims Audit Report for Managed Long-Term Care MCOs | DMS | None |
| F-02702 | Pre-Release Enrollment Agreement | DPH | None |
| F-02140 | Urgent Services Agreement | DPH | None |
| F-82064 | Background Information Disclosure (BID) | DQA | None |
| F-02768 | COVID-19 Wasted Vaccine Record | DPH | None |
| F-01238 | Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs | DPH | None |
| F-02047 | IRIS Financial Reporting Template | DMS | None |
| F-01284 | Family Care, Family Care Partnership, and PACE Financial Reporting | DMS | None |
| F-02605 | Home and Community-Based Services (HCBS) Settings Rule | DMS | None |
| F-10112 | Medicaid Disability Application | DMS | Other |
| F-16066 | FoodShare Wisconsin Income Change Report | DMS | Other |
| F-10119 | Temporary Enrollment for Family Planning Only Services | DMS | Other |
| F-10081 | BadgerCare Plus – Express Enrollment for Pregnant Women Application | DMS | Other |
| F-01647 | Coverdell Emergency Medical Services (EMS) Partner Agreement | DPH | None |
| F-04020L | Student Immunization Record, Long | DPH | None |
| F-00963 | Children’s Long Term Support Reconciliation Packet | DMS | None |
| F-02763 | Acute Hospital Care at Home Program: Emergency Request for Approval | DQA | None |
| F-02663 | Letterhead – EVV Personal Identification Number (PIN) | DMS | None |
| F-16038 | Administrative Disqualification Hearing Notice | DMS | None |
| F-16039 | Waiver of Administrative Disqualification Hearing | DMS | None |
| F-00780 | Options Counseling Tip Card | DPH | None |
| F-02771 | COVID-19 Ventilation Checklist | CRT | None |
| F-01997 | Children's Community Options (CCOP) Reconciliation Packet | DMS | None |
| F-01628 | OARS Enrollment Letter | DCTS | None |
| F-01442A | IRIS Program Disenrollment Letter – Financial Eligibility | DMS | None |
| F-01942C | LTC FS - Release of Information Authorization | DMS | None |
| F-01942 | Long-Term Care Functional Screen (LTC-FS) - Annual Deadline | DMS | None |
| F-02602 | 1-2 Bed Adult Family Home Certification Application Request | DMS | None |
| F-01942D | LTC FS - Change in Condition - Release of Information Authorization | DMS | None |
| F-01442C | IRIS Program Disenrollment Letter – No Contact | DMS | None |
| F-01619 | OARS Welcome Letter | DCTS | None |
Pages
Last Revised: March 23, 2021
