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 Locationsort descending
F-01901 Surgical Site Infection (SSI)
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators
F-44192 Child Care Immunization Record
F-10096 Community Spouse Asset Share
F-01348C Itemized Method, Non-Salary Cost Worksheet
F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-01164 Consent for Sterilization
F-00989B Summary of Development (IFSP)
F-01427 Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC
F-01225 WISEWOMAN Health Coaching Follow-Up
F-21284 Clinician Confirmation of Diagnosis
F-80477 Canteen Operations Statement of Revenues / Expenses and Fund Equity Changes - GAAP Basis
F-20452 Criteria for High Risk of Nursing Home Admission
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization
F-11306 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older
F-00777 MAPT Vendor Related Allocation Formula
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-02057 ADRC Authorization for the Release of Confidential Information
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-02040 WIC Program Notice of Categorical Ineligibility
F-62603 Adult Day Care and Family Adult Day Care Background Character Verification
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis
F-62232 Hospice Contracts and Agreements Review
F-01821 WIC Authorized Infant Formula Supplier Application
F-47463A First Responder Operational Plan Components
F-44000 Tuberculosis Disease Initial Request for Medication
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA)
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service
F-01312 IRIS Provider Application
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-01627 OARS Provider Case Manager Checklist
F-00041 Asbestos Project Notification
F-01570 Ice Arena Equipment Maintenance Log
F-00726 Typical Vision Developmental Milestones
F-40071 Children's Physical Activity Chart
F-10150A Your Rights and Responsibilities for Health Care
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments
F-00164 Civil Rights Compliance Plan
F-01354 OARS Individual Service Plan (ISP)
F-00042 Knowledge Journal
F-01571 Air Quality Measurement Device Maintenance and Calibration Log
F-00727 Typical Hearing Developmental Milestones
F-40072 8 Week Activity Log
F-01394 Virginia Graeme Baker Act – Drain Cover Replacement Log
F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment


Last Revised: May 22, 2018