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.
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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 | None |
| F-19002 | Request to Reduce QUEST Card Balance | None |
| F-02363 | Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies | None |
| 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 | None |
| F-10150 | Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare | None |
| F-10150A | Your Rights and Responsibilities for Health Care | None |
| F-16026 | Prosecution Diversion Agreement | None |
| F-00596 | PPS Mental Health Module | None |
| F-00596a | PPS Mental Health Deskcard | None |
| F-00588 | PPS Alcohol and Other Drug Abuse Module | None |
| F-62696 | Student Nurse / Graduate Nurse Verification | None |
| F-82064 | Background Information Disclosure (BID) | None |
| F-01205M | IRIS Participant Education: Restrictive Measures | None |
| F-01261 | Fraud Statement - IRIS Program | None |
| F-01205P | IRIS Participant Education: Background Check Process | None |
| F-01205E | IRIS Participant Education: Program Integrity - Budget Monitoring | None |
| F-01205 | IRIS Participant Education: Self-Direction Responsibilities | None |
| F-01205K | IRIS Participant Education: Annual Health Care Information | None |
| F-01205A | IRIS Participant Education: Health and Safety - Incident Reporting | None |
| F-01205J | IRIS Participant Education: Self-Directed Personal Care | None |
| F-01205I | IRIS Participant Education: Program Integrity - Conflict of Interest | None |
| F-01205B | IRIS Participant Education: Budget Amendments | None |
| F-01205C | IRIS Participant Education: One-Time Expense Requests | None |
| F-01205D | IRIS Participant Education: Program Integrity - Fraud Prevention | None |
| F-01020 | Nursing Home Care Determination Request | None |
| F-01205G | IRIS Participant Education: Notices of Action and Appeals | None |
| F-11237 | Specialized Medical Vehicle Providers Affidavit | None |
| F-02008 | CLTS Waivers Certification Exam | None |
| F-021343G | AFCSP Fiscal Report | None |
| F-62546 | Corporate Guardianship Program Annual Report | None |
| F-40085 | WIC Program Notice of Ineligibility | None |
| F-82069 | Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities | None |
| F-02040 | WIC Program Notice of Categorical Ineligibility | None |
| F-80025 | Forms / Publications Order | None |
| F-02340 | Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement | None |
| F-00851 | AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification | None |
| F-00681AL | Family Care – Three (3) Managed Care Organization (MCO) Options (Large Print) | None |
| F-00681BL | Partnership - Two (2) Managed Care Organization (MCO) Options (Large Print) | None |
| F-00681CCCL | Family Care - Managed Care Organization (MCO) Four Options (Large Print) | None |
| F-00681CL | Family Care - Managed Care Organization (MCO) Two Options (Large Print) | None |
| F-00681DL | IRIS (Include, Respect, I Self-Direct) Two Consultant Agency Options (Large Print) | None |
| F-00681DDL | IRIS (Include, Respect, I Self-Direct) Four Consultant Agency Options (Large Print) | None |
| F-00681L | Partnership - Three (3) Managed Care Organization (MCO) Options (Large Print) | None |
| F-00681DDDL | IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options (Large Print) | None |
| F-00805 | Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators | None |
| F-02265 | Latent Tuberculosis Infection (LTBI) Confidential Case Report | None |
| F-00079 | Prior Authorization Drug Attachment for Modafinil and Nuvigil | None |
| F-00081 | Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine | None |
| F-10161 | Statement of Citizenship and/or Identity | None |
| F-00238 | Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents | None |
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Last Revised: May 22, 2018
