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 Language
F-62579 Post Survey Questionnaire English
F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification (PDF, 97 KB) English
F-16014 Notice of Program Violation (PDF, 43 KB) English
F-00569 Request for Waiver of Administrative Rule for Licensure English
F-47471 Emergency Medical Technician Verification of Licensure English
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs English
F-00355 Healthiest Wisconsin 2020 Implementation Plan Endorsement English
F-44819 Farmers Market Nutrition Program (FMNP) - Application for Farmstands English
F-02191 CLTS County Wait List Transition Plan English
F-01454C IRIS Program Withdrawal Letter – No Contact English
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) English
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency English
F-40108 Retail Vendor Application Amendment Women, Infant, and Children (WIC) English
F-01942C LTC FS - Release of Information Authorization English
F-83263 Rehabilitation Review Application and Instructions (PDF, 61 KB) English
F-01338 CLTS Parental Fee Declaration-Model English
F-22468 Application for Services Office for the Blind and Visually Impaired English
F-01750 Request for IMD Rebalancing Initiative Funding – Detail by Member English
F-01050 Wisconsin Medicaid - Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification English
F-62645 Drug Repository Program Recipient Record English
F-01184 Wisconsin Hemophilia Home Care Program Application English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) English
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information English
F-62019 License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) English
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification (PDF, 83 KB) English
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB) English
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) English
F-02250 Quarterly Program Integrity Report English
F-01486 IRIS Consultant Biography English
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) English
F-00171 Lead Company Application English
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results (PDF, 95 KB) English
F-02026 Ethnicity and Race Selection English
F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment English
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program English
F-22637 Interagency Notification -Termination of Community Waiver Participation (PDF, 41 KB) English
F-01827 Application for Reduction of Cost Share English
F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit English
F-62692 Feeding Assistant Training Program Primary Instructor Application English
F-01201C IRIS Participant Employer / Participant-Hired Worker Agreement English
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection English
F-01580 Noncompliance Roster - Immunization (PDF, 156 KB) English
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) to treat Chronic Migraines English
F-62156 Living Unit Direct Care Staff Report - Day Shift English
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request English
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) English
F-45029 School Food Safety Program Inspection Report English
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP) English
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format English
F-00221B FAMILY CARE / PARTNERSHIP / PACE / IRIS Program Requested Disenrollment English

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Last Revised: July 28, 2017