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-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports
F-19002 Request to Reduce QUEST Card Balance
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-10150A Your Rights and Responsibilities for Health Care
F-16026 Prosecution Diversion Agreement
F-00596 PPS Mental Health Module
F-00596a PPS Mental Health Deskcard
F-00588 PPS Alcohol and Other Drug Abuse Module
F-62696 Student Nurse / Graduate Nurse Verification
F-82064 Background Information Disclosure (BID)
F-01205M IRIS Participant Education: Restrictive Measures
F-01261 Fraud Statement - IRIS Program
F-01205P IRIS Participant Education: Background Check Process
F-01205E IRIS Participant Education: Program Integrity - Budget Monitoring
F-01205 IRIS Participant Education: Self-Direction Responsibilities
F-01205K IRIS Participant Education: Annual Health Care Information
F-01205A IRIS Participant Education: Health and Safety - Incident Reporting
F-01205J IRIS Participant Education: Self-Directed Personal Care
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-01205B IRIS Participant Education: Budget Amendments
F-01205C IRIS Participant Education: One-Time Expense Requests
F-01205D IRIS Participant Education: Program Integrity - Fraud Prevention
F-01020 Nursing Home Care Determination Request
F-01205G IRIS Participant Education: Notices of Action and Appeals
F-11237 Specialized Medical Vehicle Providers Affidavit
F-02008 CLTS Waivers Certification Exam
F-021343G AFCSP Fiscal Report
F-62546 Corporate Guardianship Program Annual Report
F-40085 WIC Program Notice of Ineligibility
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities
F-02040 WIC Program Notice of Categorical Ineligibility
F-80025 Forms / Publications Order
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification
F-00681AL Family Care – Three (3) Managed Care Organization (MCO) Options (Large Print)
F-00681BL Partnership - Two (2) Managed Care Organization (MCO) Options (Large Print)
F-00681CCCL Family Care - Managed Care Organization (MCO) Four Options (Large Print)
F-00681CL Family Care - Managed Care Organization (MCO) Two Options (Large Print)
F-00681DL IRIS (Include, Respect, I Self-Direct) Two Consultant Agency Options (Large Print)
F-00681DDL IRIS (Include, Respect, I Self-Direct) Four Consultant Agency Options (Large Print)
F-00681L Partnership - Three (3) Managed Care Organization (MCO) Options (Large Print)
F-00681DDDL IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options (Large Print)
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report
F-00079 Prior Authorization Drug Attachment for Modafinil and Nuvigil
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-10161 Statement of Citizenship and/or Identity
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents

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Last Revised: May 22, 2018