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-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions
F-62096A DQA Authority for Obtaining Provider Records Without Written Release
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification
F-00264 Personal Care Agency Surveyor Guide
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis
F-11067 Record of Actual Daily Oxygen Use
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-01282 Monthly Enrollment Discrepancy Report Template - Model
F-01201 IRIS Education — Hired Worker Set-Up
F-01165 Newborn Report
F-44003 Lead-Safe Renovator Application
F-01468 IRIS Program Start Date Letter – New Participant
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older
F-40072 8 Week Activity Log
F-02367 Non-Addictive, Non-Narcotic, Injectable Medication (NNAI) Medication Assisted Treatment (MAT) Service within the Jail Setting NNAI MAT Re-Entry Grant Application
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary
F-00777 MAPT Vendor Related Allocation Formula
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-02285 Pilot of Kindergarten Public Health Report, 2017-18
F-81011 Cash Certification for Petty Cash, Canteen client / Resident and General Accounts
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-20572 Request for State Public Funding for Non-Residents
F-62680 Home Health Agency Clinical Record Review
F-00482 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Initial Certification Application - Chapter DHS 36
F-00366 Wisconsin Adult Long-Term Care Functional Screen
F-02140 Urgent Services Agreement
F-00176 Civil Money Penalty Funds Project Proposal
F-00221B Family Care / Partnership / PACE / IRIS Program Requested Disenrollment
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night
F-11304 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-01937 Wisconsin EMS Paramedic Training Record - Paramedic Refresher Requirements
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA)
F-42014 Acuity Index
F-45020 Cumulative Occupational Exposure History
F-10144 Life Insurance Inquiry
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request
F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Entities
F-00233 Renewal Summary Letter
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request
F-02034 Aging/ADRC Integration Funding Budget Worksheet
F-11306 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-01938 Wisconsin EMS Paramedic Training Record - NCCP Paramedic Refresher Requirements
F-60953 Adult Family Home Fire Safety Guide

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Last Revised: May 22, 2018