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-01950 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-13393 Trading Partner 835 Designation
F-62028 Report of Hours Worked - Nurse Aide / Night
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers
F-00989G Tell Us About Your Family (IFSP)
F-10112 Medicaid Disability Application
F-00754 Wisconsin Civil Service Request for Examination Accommodations
F-40096 eWIC Program Repayment Agreement
F-20934 Court Ordered Assessment and Plan Report
F-01204D Letter - IRIS Program Notice of Action - Termination
F-01287 Template for Transition - Initial Plan - Model
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08
F-21365 Comprehensive Community Services Startup Outcomes - 2009
F-02109 Community-Based Residential Facility (CBRF)
F-80013 Petty Cash Fund Annual Report
F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification
F-00236 Request for a State Fair Hearing - MCO
F-16024 FoodShare Notice of Disqualification
F-01999 2020 Foster Grandparent Program: State Match Funding Application
F-62224 Nurse Aide Training Program – Notice of Substantial Change
F-00017 Blood Lead Lab Reporting
F-01735 CLIA Laboratory Test Methodology Report
F-11130 Federally Qualified Health Center Interim Report
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License
F-01275A IRIS Provider Executive Staff Disclosure
F-10144 Life Insurance Inquiry
F-00888 Next Steps
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up
F-00107W Self-Employment Income Report Worksheet
F-01344 Strategies for Success with People Who Have Dementia-Behavior Analysis Worksheet-Model (PDF, 92 KB)
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-80477A Canteen Operations Analysis of Cash - GAAP Basis
F-01184 Wisconsin Hemophilia Home Care Program Application
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E)
F-62333 Plan Approval Application and Instructions
F-00049 Asbestos Principal Instructor Application
F-01798 Retroactive Overtime To Be Calculated
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification
F-45038 Wisconsin Mercury Exposure Study
F-00714 Business Associate Agreement - County or Tribal Contract
F-10183 Information Change Report
F-00943 Exhibit II - Tribal Work Plan
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC)

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Last Revised: May 22, 2018