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 | Division | Other Location |
|---|---|---|---|
| F-10182 | BadgerCare Plus Application Packet | DMS | Other |
| F-10127 | Medicaid Purchase Plan (MAPP) - Work Requirement Exemption | DMS | None |
| F-04020L | Student Immunization Record, Long | DPH | None |
| F-02577 | Proof of In-Kind Hours | DMS | None |
| F-16015 | Notice of Approval of Benefits/Positive Change in Benefits | DMS | None |
| F-00332 | Medicaid Purchase Plan Premium Information / Payment | DMS | None |
| F-16039 | Waiver of Administrative Disqualification Hearing | DMS | None |
| F-00236A | Request for a State Fair Hearing - ADRC | DPH | None |
| F-01307 | Medicaid Purchase Plan (MAPP) Eligibility Worksheet | DMS | None |
| F-02388 | MIPPA Grant Agency Application | DPH | None |
| F-10101 | Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet | DMS | Other |
| F-01454F | IRIS Program Withdrawal Letter – Death | DMS | None |
| F-01454H | IRIS Program Withdrawal Letter – Conflict of Withdrawal | DMS | None |
| F01454G | IRIS Program Withdrawal Letter – Cancelled | DMS | None |
| F-02040 | WIC Program Notice of Categorical Ineligibility | DPH | None |
| F-01891 | New Employment Reporting – FoodShare Employment and Training (FSET) Program | DMS | None |
| F-40019 | Affirmation of Identity, Residency, and/or Income | DPH | None |
| F-44763 | Emergency Care Do Not Resuscitate Order (DNR) | DPH | None |
| F-40096 | eWIC Program Repayment Agreement | DPH | None |
| F-16024 | FoodShare Notice of Disqualification | DMS | None |
| F-40028 | Participant Determination Letter | DPH | Other |
| F-10150 | Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare | DMS | None |
| F-10114 | Medicaid Disability Redetermination Report | DMS | None |
| F-02605 | Home and Community-Based Services (HCBS) Settings Rule | DMS | None |
| F-16025 | Disqualification Consent Agreement | DMS | None |
| F-16066 | FoodShare Wisconsin Income Change Report | DMS | Other |
| F-02491 | FoodShare Buy and Make Food Separately | DMS | None |
| F-16026 | Prosecution Diversion Agreement | DMS | None |
| F-40076 | Women, Infants, and Children (WIC) Nutrition Program Employer Statement | DPH | None |
| F-40036 | Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor | DPH | None |
| F-44161 | WIC Rights and Responsibilities | DPH | Other |
| F-02431 | Statement About U.S. Military Service | DMS | None |
| F-16028 | Notice of FoodShare Overissuance | DMS | None |
| F-40085 | WIC Program Notice of Ineligibility | DPH | None |
| F-02340 | Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement | DMS | None |
| F-19002 | Request to Reduce QUEST Card Balance | DMS | None |
| F-44764 | Do Not Resuscitate Bracelet - Electronic Format | DPH | None |
| F-44161A | WIC Cardholder Rights and Responsibilities | DPH | None |
| F-16038 | Administrative Disqualification Hearing Notice | DMS | None |
| F-16001 | Notice of Denial of Benefits/Negative Change in Benefits | DMS | None |
| F-40044 | Participant Agreement, Rights & Responsibilities | DPH | Other |
| F-16004 | Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits | DMS | None |
| F-10121 | Medicaid Purchase Plan (MAPP) Independence Account Registration | DMS | None |
| F-02603 | Request for a Temporary Waiver of MAPP Premium | DMS | None |
| F-01542 | Notification of Required Drug Testing | DMS | None |
| F-02700 | Wisconsin COVID-19 Patient Information | DPH | None |
| F-00851 | AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification | DPH | None |
| F-00036 | Power of Attorney for Finance and Property | DPH | None |
| F-10137 | Medicaid Change Report | DMS | None |
| F-62457 | Request for Permission to Start Construction for Footings and Foundations | DQA | None |
Pages
Last Revised: March 26, 2019
