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-01442A IRIS Program Disenrollment Letter – Financial Eligibility
F-05260 Letter of Non-Marriage Application
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment
F-05281 Wisconsin Marriage Certificate Application
F-01556D IRIS Program Letter – Disenrollment
F-01442C IRIS Program Disenrollment Letter – No Contact
F-05282 Wisconsin Divorce Certificate Application
F-01442i IRIS Program Disenrollment Letter - Cancelled
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting
F-05291 Wisconsin Birth Certificate Application
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-01468 IRIS Program Start Date Letter – New Participant
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-02047 IRIS Financial Reporting Template
F-01442G IRIS Program Disenrollment Letter – Non-Spending
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization
F-01398 WISEWOMAN Client Home Blood Pressure Monitoring Agreement
F-01219-pckt WISEWOMAN Integrated Office Visit Assessment Packet
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral
F-01225 WISEWOMAN Healthy Behavior Encounter
F-00476 CARES Automated Systems Access Request
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete
F-02431 Statement About U.S. Military Service
F-20445 Individual Service Plan – Children’s Long-Term Support Programs
F-16019A FoodShare Wisconsin Registration
F-16019B FoodShare Wisconsin Registration Packet
F-00107W Self-Employment Income Report Worksheet
F-00219W Self-Employment Income Report: Farm Business Worksheet
F-29314 COP Declaration of Income and Assets, and State Residency
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies
F-82009II WIC Confidential Information Release Authorization
F-02476 Nurse Aide Federal Employment Eligibility Renewal Waiver Request
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster
F-26100 Client Rights Limitation or Denial Documentation
F-16076 FoodShare Six-Month Report and Instructions
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA)
F-62504 Behavioral Health Certification Section: Initial Certification Application
F-01309 IRIS Program Orientation and Enrollment Checklist
F-02306 Application for Telecommunication Assistance Program (TAP)
F-01212 Grievance - IRIS Program
F-62096A DQA Authority for Obtaining Provider Records Without Written Release
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request
F-00533 PACE / Partnership Programs - Enrollment
F-00046 Family Care Program - Enrollment
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization
F-44160A WIC Plastic Cover for WIC ID Folder (order in multiples of 200)


Last Revised: March 26, 2019