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 Language
F-11081 Wisconsin Medicaid Rural Health Clinic Provider Staff Encounters English
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels English
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) English
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) English
F-40093 Annual ROSIE User Security and Confidentiality Agreement English
F-00777 MAPT Vendor Related Allocation Formula English
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research English
F-01320 Lead Test Kit Documentation English
F-21365 Comprehensive Community Services Startup Outcomes - 2009 English
F-83271 DHS Website Feedback English
F-00468 CSAS Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 English
F-62610 Nurse Aide Training Program Primary Instructor Application English
F-01168 Wisconsin Medicaid - Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases English
F-16029 FoodShare Wisconsin Repayment Agreement English
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool English
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents English
F-60309 Self-Supervision Evaluation and Waiver Request English
F-01205M IRIS Participant Education: Restrictive Measures English
F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) English
F-00027 CSAS Standards Recertification Application - DHS 75.03 English
F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices English
F-00726 Typical Vision Developmental Milestones English
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) English
F-42007 Mail Label 3 X 4 - Immunization Program English
F-00891 Abuse and Neglect Prevention Training - DVD Request (PDF, 20 KB) English
F-01223 WISEWOMAN Case Management English
F-01352 Background Check Appeal Request - IRIS Program English
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors (PDF, 21 KB) English
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys English
F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 English
F-62674 Home Health Agency License Application English
F-01200 IRIS Program Cost Share Repayment Agreement English
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation English
F-01748 Tuberculosis (TB) Risk Assessment Questionnaire Screen English
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs English
F-62069A Personal Care Agency Complaint Report English
F-01627 OARS Provider Case Manager Checklist English
F-12023 Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption English
F-00053 Notice of Intent to Submit an Application (ADRC) English
F-45020 Cumulative Occupational Exposure History (PDF, 149 KB) English
F-00989A Child and Family Information (IFSP) English
F-10191 Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) English
F-43016 Prevent Heart Disease & Stroke Wallet Card (PDF, 499 KB) English
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet English
F-01367 Wisconsin WIC Referral/Communication to CYSHCN Regional Center English
F-05023 Acknowledgement of Marital Child English
F-25207 Order Granting Capias English
F-11134 Personal Care Prior Authorization Provider Acknowledgement English
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 English
F-69311 Quality of Life Assessment - Family Interview CMS-806C English

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Last Revised: July 28, 2017