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 Division Other Location
F-02715 ADRC Client Tracking System Waiver Request DPH
F-02714 ADRC Professional Training Participant Survey DPH
F-02716 Authorization to Allocate Elder Benefit Specialist Funding to the Aging and Disability Resource Center DPH
F-10187 Divestment Penalty and Undue Hardship Notice DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-82009W Confidential Information Release Authorization: Two Entities OLC
F-02558 Family Care Member County Notification DMS
F-01389 MHSIP Adult Satisfaction Survey DCTS
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application DCTS
F-02122 Opioid Crisis State Targeted Response Program Funding Request DCTS
F-44016 Asbestos Occupant Protection Plan DPH
F-42000 Vaccine Order DPH
F-00330 Request for Replacement FoodShare Benefits DMS
F-01201 IRIS Participant-Hired Worker Set-Up DMS
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Belsomra and Dayvigo DMS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request DMS
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request DMS
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request DMS
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-01184 Wisconsin Hemophilia Home Care Program Application DMS
F-01185 Wisconsin Adult Cystic Fibrosis Program Application DMS
F-10112 Medicaid Disability Application DMS
F-10097 Medicaid Income Allocation Notice DMS
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-10150B Your Rights and Responsibilities for FoodShare DMS
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-62495 Compliance Statement DQA
F-62652 Home Health Agency Licensure Survey Home Visit Guide DQA
F-02642 Report a Change in Circumstance to Income Maintenance Agencies DMS
F-02706 Recovery Residence Registry Application DQA
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility DMS
F-02341A Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration DMS
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist DMS
F-01316 Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet DMS
F-01297 Medicaid Institution Determination Worksheet DMS
F-16019A FoodShare Wisconsin Registration DMS
F-10182 BadgerCare Plus Application Packet DMS
F-16019B FoodShare Wisconsin Registration Packet DMS
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-04020L Student Immunization Record, Long DPH
F-02577 Proof of In-Kind Hours DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-00332 Medicaid Purchase Plan Premium Information / Payment DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS

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Last Revised: March 26, 2019