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-00049 Asbestos Principal Instructor Application DPH
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application DMS
F-00703 Patient Side Training Report DPH
F-16029 FoodShare Wisconsin Repayment Agreement DMS
F-05291 Wisconsin Birth Certificate Application DPH
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-00107 Self-Employment Income Report DMS
F-02461 Tuberculosis (TB) Treatment Assistance Program - Special Request DPH
F-40041 Certification and Food Package Pick-Up DPH
F-21276A DCTS Coordinated Services Teams (CST) Grant / Contract Application Summary DCTS
F-02462 Tuberculosis (TB) Treatment Assistance Enrollment and Agreement DPH
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-01542 Notification of Required Drug Testing DMS
F-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP) DMS
F-00086 Authorization for Final Disposition DPH
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-02324 Wisconsin’s American Sign Language Interpreter, SSP and CART Directory Sign-Up and/or Change Request DPH
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS
F-02536 Nursing Home: Waiver or Variance Request DQA
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs DQA
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-02522 Supervised Release Individual Client Summary DCTS
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services DPH
F-80983 Civil Rights Complaint DES
F-00236 Request for a State Fair Hearing - MCO DMS
F-02491 FoodShare Buy and Make Food Separately DMS
F-44161 WIC Rights and Responsibilities DPH
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-16076 FoodShare Six-Month Report and Instructions DMS
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bed-Hold Days DMS
F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) DPH
F-10097 Medicaid Income Allocation Notice DMS
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities DQA
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-01389B MHSIP Family Satisfaction Survey DCTS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-01389 ROSI Adult Satisfaction Survey DCTS
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-22540 Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs OPIB
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS
F-80881 Profile ID Request (CARS) DES
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH

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Last Revised: March 26, 2019