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 Number Title Division Other Location
F-01942C LTC FS - Release of Information Authorization DMS
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline DMS
F-02602 1-2 Bed Adult Family Home Certification Application Request DMS
F-01942D LTC FS - Change in Condition - Release of Information Authorization DMS
F-01827 Application for Reduction of Cost Share DMS
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS DMS
F-00913 Annual Survey of Nursing Homes DQA
F-82003 Denial of Researcher Access To Health Care Records OLC
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter DMS
F-01556 Medicaid Cost Share Letter - Initial DMS
F-00688 Referral to Wisconsin Birth to 3 Program DMS
F-021343G AFCSP Fiscal Report DPH
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter DMS
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter DMS
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter DMS
F-01556C IRIS Program Cost Share Repayment Plan Letter DMS
F-21353i CLTS One Time High-Cost Notification Instructions and Typical Ranges DMS
F-01556D IRIS Program Letter – Disenrollment DMS
F-01454E IRIS Program Withdrawal Letter – Voluntary DMS
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-01454F IRIS Program Withdrawal Letter – Death DMS
F-01415 IRIS Adult Family Home Taxable Income Information DMS
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter DMS
F-01454 IRIS Program Withdrawal Letter – No Progress DMS
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting DMS
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility DMS
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page DMS
F-01442J IRIS Program Disenrollment Letter - Mismanagement DMS
F-21353 CLTS One Time High-Cost Notification DMS
F-02749 CLTS Exceptional Expense Notification DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS
F-01442G IRIS Program Disenrollment Letter – Non-Spending DMS
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-01454C IRIS Program Withdrawal Letter – No Contact DMS
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F01454G IRIS Program Withdrawal Letter – Cancelled DMS
F-01319C IRIS Program – Denial of Enrollment Letter DMS
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility DMS
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change DMS
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter DMS
F-01204C Letter – IRIS Program Notice of Action – Reduction DMS
F-01204D Letter – IRIS Program Notice of Action – Termination DMS
F-01204E Letter – IRIS Program Notice of Action – Functional Eligibility DMS

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Last Revised: March 23, 2021