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-45023 Certificate - Use of Depleted Uranium under General License
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-00989K Transition Plan - Other (IFSP)
F-11008 Prior Authorization / Therapy Attachment (PA/TA)
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC)
F-00330 Request for Replacement FoodShare Benefits
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary
F-05027A Report of Citizenship
F-25392 Petition for Re-Examination
F-02110 Residential Care Apartment Complex (RCAC)
F-00100 State Vital Records Birth Certificate Request Letter
F-80130 Financial Information 
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-20817 Assessment Worksheet for Natural Residential Setting
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES)
F-62319 Hospice Volunteer Program Review
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness
F-42014 Acuity Index
F-13073 Compound Drug Claim
F-47181 First Responder Certification Card
F-00596 PPS Mental Health Module
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA)
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months
F-00681C Family Care - Managed Care Organization (MCO) Two (2) Options
F-05210 Name Change Request Within 1st Year
F-29321 COP Cost-Share Worksheet #2
F-02230 County Agency Children's Community Option Program (CCOP) Annual Plan Update
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum
F-80783A Family Financial Questionnaire - County Use
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-20987 Authorized Representative Designation, Medicaid Community Waiver Programs
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-62494 Health Care Facility Construction Documentation Checklist
F-01068A General Pediatric Clinic - 3 to 4 Week Visit
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request
F-47461A Label-Wash
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-01586 Medical Stockpile Access Request
F-11051 Prior Authorization / Vision Services Attachment (PA/VA)
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
F-00390 Incident Report - Community Recovery Services (CRS)
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice
F-40060 The Emergency Food Assistance Program Commodities Inventory Report
F-02282 Resident Relocation Roster
F-00191A Certified Outpatient Clinic Request for a School Branch Office
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids

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Last Revised: July 28, 2017