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| Assigned Number | Title | Division | Other Location |
|---|---|---|---|
| F-01942C | LTC FS - Release of Information Authorization | DMS | None |
| F-01942 | Long-Term Care Functional Screen (LTC-FS) - Annual Deadline | DMS | None |
| F-02602 | 1-2 Bed Adult Family Home Certification Application Request | DMS | None |
| F-01942D | LTC FS - Change in Condition - Release of Information Authorization | DMS | None |
| F-01827 | Application for Reduction of Cost Share | DMS | None |
| F-01337 | Worksheet for Determination of Parental Payment Limit for CLTS | DMS | None |
| F-00913 | Annual Survey of Nursing Homes | DQA | None |
| F-82003 | Denial of Researcher Access To Health Care Records | OLC | None |
| F-01563 | IRIS Consultant Agency (ICA) Provider Change Letter | DMS | None |
| F-01556 | Medicaid Cost Share Letter - Initial | DMS | None |
| F-00688 | Referral to Wisconsin Birth to 3 Program | DMS | None |
| F-021343G | AFCSP Fiscal Report | DPH | None |
| F-01556BB | IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter | DMS | None |
| F-01556A | IRIS Program First Delinquent Medicaid Cost Share Payment Letter | DMS | None |
| F-20919 | Medicaid Waiver Eligibility and Cost Sharing Worksheet | DMS | None |
| F-01556E | IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer | DMS | None |
| F-01556B | IRIS Program Second Delinquent Medicaid Cost Share Payment Letter | DMS | None |
| F-01556C | IRIS Program Cost Share Repayment Plan Letter | DMS | None |
| F-21353i | CLTS One Time High-Cost Notification Instructions and Typical Ranges | DMS | None |
| F-01556D | IRIS Program Letter – Disenrollment | DMS | None |
| F-01454E | IRIS Program Withdrawal Letter – Voluntary | DMS | None |
| F-01454H | IRIS Program Withdrawal Letter – Conflict of Withdrawal | DMS | None |
| F-01454F | IRIS Program Withdrawal Letter – Death | DMS | None |
| F-01415 | IRIS Adult Family Home Taxable Income Information | DMS | None |
| F-01293C | Fiscal Employer Agent (FEA) Change Effective Date Letter | DMS | None |
| F-01454 | IRIS Program Withdrawal Letter – No Progress | DMS | None |
| F-11268 | BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification | OIG | None |
| F-01442E | IRIS Program Disenrollment Letter – Ineligible Setting | DMS | None |
| F-01442i | IRIS Program Disenrollment Letter - Cancelled | DMS | None |
| F-11309 | BadgerCare Plus Express Enrollment for Children Provider Certification | OIG | None |
| F-01454A | IRIS Program Withdrawal Letter – Financial or Functional Eligibility | DMS | None |
| F-01442F | IRIS Program Disenrollment Letter – Missing Signature Page | DMS | None |
| F-01442J | IRIS Program Disenrollment Letter - Mismanagement | DMS | None |
| F-21353 | CLTS One Time High-Cost Notification | DMS | None |
| F-02749 | CLTS Exceptional Expense Notification | DMS | None |
| F-01454B | IRIS Program Withdrawal Letter – Health and Safety | DMS | None |
| F-01442G | IRIS Program Disenrollment Letter – Non-Spending | DMS | None |
| F-01442K | IRIS Program Disenrollment Letter - Policy Noncompliance | DMS | None |
| F-01454C | IRIS Program Withdrawal Letter – No Contact | DMS | None |
| F-01442H | IRIS Program Disenrollment Letter – Voluntary | DMS | None |
| F01454G | IRIS Program Withdrawal Letter – Cancelled | DMS | None |
| F-01319C | IRIS Program – Denial of Enrollment Letter | DMS | None |
| F-01454D | IRIS Program Withdrawal Letter – Non Eligible Setting | DMS | None |
| F-01442D | IRIS Program Disenrollment Letter – Incomplete Functional Screen | DMS | None |
| F-01442B | IRIS Program Disenrollment Letter – Functional Eligibility | DMS | None |
| F-01204F | IRIS Program Notice of Action Letter – Denied Provider Change | DMS | None |
| F-01293B | Fiscal Employer Agent (FEA) Change Denial Letter | DMS | None |
| F-01204C | Letter – IRIS Program Notice of Action – Reduction | DMS | None |
| F-01204D | Letter – IRIS Program Notice of Action – Termination | DMS | None |
| F-01204E | Letter – IRIS Program Notice of Action – Functional Eligibility | DMS | None |
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Last Revised: March 23, 2021
