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-00568 EMS Board Sub-Committee Appointment Application
F-01604 Telehealth Application – Annual Review of Approval
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2)
F-44013 Lead-Based Paint (LBP) Investigation Summary Report
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-05044 Cause of Death Amendment
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program
F-00123 Wisconsin Declaration of Domestic Partnership Application
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research
F-01212 Grievance - IRIS Program
F-20941A Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration
F-02080 Dementia Crisis Innovation Grants: Round Two
F-62589 Telehealth Application – Initial Approval
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease
F-01939 Wisconsin Medicaid Waiver Provider Registration
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request
F-47478 First Responder / Emergency Medical Technician Application Electronic Addition to a Roster
F-00628 Consortium Response to the State IM Second Party Review Finding
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up
F-00726 Typical Vision Developmental Milestones
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application
F-40054 Confidential Birth Defects Registry Report
F-00681BL Partnership - Two (2) Managed Care Organization (MCO) Options (Large Print)
F-00166 Service Delivery or Employment Discrimination Complaint
F-01223 WISEWOMAN Case Management
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-21080A Children's Long-Term Support (CLTS) Waivers Application Checklist - Step Two
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications
F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits
F-01068H General Pediatric Clinic - 18 Month Visit
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review
F-13470 Claim Form Attachment Cover Page
F-62023 Report of Hours Worked - Registered Nurse / Day
F-00688 Referral to Wisconsin Birth-3 Program
F-01354 OARS Individual Service Plan (ISP)
F-11076A Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for Initial Admission and Unplanned Readmission within 90 Days of Discharge from RCC
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets
F-00989B Summary of Development (IFSP)
F-10115 BadgerCare Plus / Medicaid Health Insurance Information
F-40085 WIC Program Notice of Ineligibility
F-00219 Self-Employment Income Report: Farm Business
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center
F-01302 Weekly Driver's Vehicle Inspection Report
F-01309 IRIS Program Orientation and Enrollment Checklist

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Last Revised: May 22, 2018