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-16039 Waiver of Administrative Disqualification Hearing
F-00123 Wisconsin Declaration of Domestic Partnership Application
F-16050 Agency Position on the State Quality Control (QC) Finding
F-01459 Tuberculosis (TB) Program Dispensary Pre-Authorization for Non-Routine TB Services
F-25615 Supervised Release Rules
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification
F-45029 School Food Safety Program Inspection Report
F-82009II WIC Confidential Information Release Authorization
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request
F-10175 Statement of Identity for Persons in Institutional Care Facilities
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information
F-43013 Diabetes Medical Management Plan
F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide
F-01931 Wisconsin EMS AEMT Training Record - AEMT Refresher Requirements
F-04020 Student Immunization Record - This form is intended for schools
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB)
F-25177 Statement of Probable Cause and Detention and Petition for Revocation
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-01201 IRIS Education — Hired Worker Set-Up
F-00166 Service Delivery Discrimination Complaint
F-20452 Criteria for High Risk of Nursing Home Admission
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request
F-00681CL Family Care - Managed Care Organization (MCO) Two Options (Large Print)
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions
F-01068i General Pediatric Clinic - 24 Month Visit
F-47247 Ambulance Attendant License/Permit Renew
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral
F-02122 Opioid Crisis State Targeted Response Program Funding Request
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines
F-44014 Lead-Free Inspection Affidavit of Property Owner
F-62646 Home Health Agency (HHA) Patient Rights Statement Review
F-01765 TEFAP Food Pantry Self-Assessment Tool
F-05032 Report of Birth Certificate Changes After Surrogate Birth
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11)
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant
F-01626 OARS Facility Checklist
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-00219 Self-Employment Income Report: Farm Business
F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care
F-00989A Child and Family Information (IFSP)
F-00010 Risk Agreement - Participant
F-02377 Supported Decision-Making Agreement
F-13150 HIPAA Privacy Alternate Communication Request
F-47479 Trauma Care Facility Classification Application
F-00989-Packet Individualized Family Service Plan (IFSP) Packet
F20418 Agency Application for Access to Web-Based Personal Care Screening Tool
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA)
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification


Last Revised: May 22, 2018