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 Other Location
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04
F-00714 Business Associate Agreement - County or Tribal Contract
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC)
F-01165 Newborn Report
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments
F-01442 IRIS Disenrollment Letter - Death
F-25392 Petition for Re-Examination
F-02288 WisCaregiver Career Program – Registration Agreement
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC
F-80952A Contingency Plan - DHS Regional Offices
F-11260 Degree Addendum
F-20812 SSI-E Natural Residential Setting Application Checklist
F-02059 New Carrier Insurance Disclosure Onboarding
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing
F-10161 Statement of Citizenship and/or Identity
F-00987 EMS Service Operational Plan, Advanced Skills Addendum (Basic)
F-01892 Symptomatic Urinary Tract Infection
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan
F-01352 Background Check Appeal Request - IRIS Program
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-01631 ADRC Call Summary Sheet
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women
F-01199 Optional School-Based Services Activity Medication Administration
F-00336 Tickborne Rickettsial Disease Case Report
F-01454C IRIS Program Withdrawal Letter – No Contact
F-29321 COP Cost-Share Worksheet #2
F-25393A Petition for Supervised Release
F-00114 EMS Service Director License Proxy for Individuals
F-83263 Rehabilitation Review Application and Instructions
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request
F-20985 Participant Rights and Responsibilities Notification
F-02117 Home and Community-Based Settings - Adult Residential Provider Assessment
F-62603 Adult Day Care and Family Adult Day Care Background Character Verification
F-10193 Undue Hardship Waiver Request
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement
F-01935 WIconsin EMS First Responder Training Record - NCCP First Responder Refresher Requirements
F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey
F-05024 Voluntary Paternity Acknowledgement
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP)
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years
F-01486 IRIS Consultant Biography
F-40060 The Emergency Food Assistance Program Commodities Inventory Report
F-00681DDDL IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options (Large Print)
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment
F-13145 HIPAA Privacy Authorization for Use or Disclosure
F-21189 Rights of Detention

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Last Revised: May 22, 2018