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.
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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-00113 | Four Conditions for the Use of Funding in a CBRF | None | English |
| F-00114 | Service Director License Proxy for Individuals | None | English |
| F-00115 | Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument | None | English |
| F-00119 | Personal Care Agency Application for Approval | None | English |
| F-00123 | Wisconsin Declaration of Domestic Partnership Application | None | English |
| F-00124 | Wisconsin Termination Domestic Partnership Certificate Application | None | English |
| F-00136 | FoodShare Employment and Training (FSET) Program Participation Agreement | None | English |
| F-00140 | Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency | None | English |
| F-00142 | Prior Authorization / Drug Attachment for Synagis | None | English |
| F-00152 | MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate | None | English |
| F-00152A | Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request | None | English |
| F-00154 | Wisconsin Consultative Examination Inquiry | None | English |
| F-00157 | Assisted Living Administrator Training Course - Trainer Approval Application | None | English |
| F-00158 | Assisted Living Administrator Training Course - Application for Training Curriculum | None | English |
| F-00161 | Caregiver Misconduct Reporting Requirements Worksheet (PDF, 48 KB) | None | English |
| F-00161A | Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source (PDF, 22 KB) | None | English |
| F-00162 | Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids | None | English |
| F-00163 | Prior Authorization / Drug Attachment for Anti-Obesity Drugs | None | English |
| F-00164 | Civil Rights Compliance Plan | None | English |
| F-00165 | Civil Rights Compliance Letter of Assurance | None | English |
| F-00166 | Service Delivery / Employment Discrimination Complaint | None | English |
| F-00167 | Civil Rights Complaint Consent/Release | None | English |
| F-00169 | Opting Out of Local Educational Agency (LEA) Notification | None | English |
| F-00171 | Lead Company Application | None | English |
| F-00176 | Civil Money Penalty Funds Project Proposal | None | English |
| F-00180 | WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies | None | English |
| F-00180A | WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers | None | English |
| F-00180B | WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports | None | English |
| F-00180C | Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals | None | English |
| F-00191 | Certified Outpatient Clinic Request for a Branch Office | None | English |
| F-00191A | Certified Outpatient Clinic Request for a School Branch Office | None | English |
| F-00192 | Referral / Communication Wisconsin WIC Program | None | English |
| F-00193 | Pediatric Referral / Communication Wisconsin WIC Program | None | English |
| F-00194 | Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids | None | English |
| F-00195 | IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program | None | English |
| F-00201 | Occupant Protection Plan (Checklist for Lead-Based Paint Activities) | None | English |
| F-00202 | Individual Service Plan - Community Recovery Services (CRS) | None | English |
| F-00203 | Community Recovery Services (CRS) - County / Tribal Agency Application | None | English |
| F-00212 | Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment | None | English |
| F-00219 | Self-Employment Income Report - Farmer | None | English |
| F-00219W | Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) | None | English |
| F-00221 | Family Care / IRIS Member Requested Disenrollment | None | English |
| F-00221A | Family Care / Partnership / PACE / IRIS - Disenrollment Routing | None | English |
| F-00221B | Family Care / Partnership / PACE / IRIS - Refusal to Accept Services and MCO Requested Disenrollment Routing | None | English |
| F-00232 | Notice of Action - MCOs | None | English |
| F-00233 | Renewal Summary Letter | None | English |
| F-00236 | Request for a State Fair Hearing - MCO | None | English |
| F-00236A | Request for a State Fair Hearing - ADRC | None | English |
| F-00236B | Request for a State Fair Hearing - IRIS | None | English |
| F-00237 | Appeal Request - MCOs | Other | English |
Pages
Last Revised: July 28, 2017
