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-02404 | Family Care, Partnership, PACE, or IRIS Change Routing Instructions | DPH | None |
| F-00075 | IRIS (Include, Respect, I Self-Direct) Authorization | DPH | None |
| F-16019A | FoodShare Wisconsin Registration | DMS | Other |
| F-02717 | Electronic Visit Verification (EVV) Live-in Worker Identification | DMS | None |
| F-02022 | Claims Audit Report for Managed Long-Term Care MCOs | DMS | None |
| F-02702 | Pre-Release Enrollment Agreement | DPH | None |
| F-02140 | Urgent Services Agreement | DPH | None |
| F-82064 | Background Information Disclosure (BID) | DQA | None |
| F-01238 | Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs | DPH | None |
| F-02768 | COVID-19 Wasted Vaccine Record | DPH | None |
| F-02047 | IRIS Financial Reporting Template | DMS | None |
| F-02605 | Home and Community-Based Services (HCBS) Settings Rule | DMS | None |
| F-01284 | Family Care, Family Care Partnership, and PACE Financial Reporting | DMS | None |
| F-16066 | FoodShare Wisconsin Income Change Report | DMS | Other |
| F-10112 | Medicaid Disability Application | DMS | Other |
| F-10119 | Temporary Enrollment for Family Planning Only Services | DMS | Other |
| F-10081 | BadgerCare Plus – Express Enrollment for Pregnant Women Application | DMS | Other |
| F-01647 | Coverdell Emergency Medical Services (EMS) Partner Agreement | DPH | None |
| F-04020L | Student Immunization Record, Long | DPH | None |
| F-02763 | Acute Hospital Care at Home Program: Emergency Request for Approval | DQA | None |
| F-00963 | Children’s Long Term Support Reconciliation Packet | DMS | None |
| F-02663 | Letterhead – EVV Personal Identification Number (PIN) | DMS | None |
| F-16038 | Administrative Disqualification Hearing Notice | DMS | None |
| F-16039 | Waiver of Administrative Disqualification Hearing | DMS | None |
| F-00780 | Options Counseling Tip Card | DPH | None |
| F-02771 | COVID-19 Ventilation Checklist | CRT | None |
| F-01997 | Children's Community Options (CCOP) Reconciliation Packet | DMS | None |
| F-01894 | Vendor Overpayment Findings Letter | DMS | None |
| F-01442 | IRIS Disenrollment Letter - Death | DMS | None |
| F-01942B | LTC FS - Request Letter | DMS | None |
| F-01628 | OARS Enrollment Letter | DCTS | None |
| F-01442A | IRIS Program Disenrollment Letter – Financial Eligibility | DMS | None |
| 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-01442C | IRIS Program Disenrollment Letter – No Contact | DMS | None |
| F-01619 | OARS Welcome Letter | DCTS | None |
| F-01942A | LTC FS - Diagnosis Verification Letter | 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-21353i | CLTS One Time High-Cost Notification Instructions and Typical Ranges | DMS | None |
| F-01556C | IRIS Program Cost Share Repayment Plan Letter | DMS | None |
| F-01556D | IRIS Program Letter – Disenrollment | DMS | None |
| F-01563 | IRIS Consultant Agency (ICA) Provider Change Letter | DMS | None |
| F-01556 | Medicaid Cost Share Letter - Initial | DMS | None |
| F-021343G | AFCSP Fiscal Report | DPH | None |
| F-01556BB | IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter | DMS | None |
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Last Revised: March 23, 2021
