Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Numbersort descending Title Division Other Location
F-00161 Caregiver Misconduct Reporting Requirements Worksheet DQA
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-00164 Civil Rights Compliance Plan OLC
F-00165 Civil Rights Compliance Letter of Assurance OLC
F-00166 Service Delivery Discrimination Complaint DES
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-00171 Lead Company Certification Application DPH
F-00176 Civil Money Penalty Funds Project Proposal DQA
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-00191 Certified Outpatient Clinic: Request for a Branch Office DQA
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids DMS
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application DCTS
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-00233 Renewal Summary Letter DMS
F-00236 Request for a State Fair Hearing - MCO DMS
F-00236A Request for a State Fair Hearing - ADRC DPH
F-00236B Request for a State Fair Hearing - IRIS DMS
F-00238 Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents DMS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-00261 Personal Care Agency Personnel Record Review DQA
F-00262 Personal Care Agency Application Materials Checklist DQA
F-00262A Personal Care Agency Application Regulatory Guidance Checklist DQA
F-00263 Personal Care Agency Record Review DQA
F-00264 Personal Care Agency Surveyor Guide DQA
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application DCTS
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service DQA
F-00309 Medicaid Provider Report DQA
F-00311 Nursing Home MDS 3.0 Section Q Referral DQA
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS
F-00315 Written Prior Notice DMS
F-00315A Written Prior Notice - No Evaluation Recommended DMS

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Last Revised: March 23, 2021