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 Locationsort descending
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application
F-01769 TEFAP Soup Kitchen Self-Assessment
F-01798 Retroactive Overtime To Be Calculated
F-47141 Emergency Medical Technician-Paramedic Training Permit Application
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP)
F-01556D IRIS Program Letter – Disenrollment
F-42029 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) and/or Varicella Vaccine
F-01285 Quarterly MCO Consolidated Financial Report Template - Model
F-01201B IRIS Supportive Home Care / Self-Directed Personal Care / Respite Care Training Verification
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-01068C General Pediatric Clinic - 4 Month Visit
F-00913 Annual Survey of Nursing Homes
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting
F-02377 Supported Decision-Making Agreement
F-01207A IRIS Fiscal / Employer Agent Quality Management Plan Tracking
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-22018 HSRS Long-Term Support Module - Module Type A
F-80976 Employment and Education History Summary
F-16076 FoodShare Six-Month Report and Instructions
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint
F-00615 Change Project Report and Instructions
F-11129B-H Federally Qualified Health Center Cost Report Forms
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36
F-11019 Prior Authorization / Physician Otological Report (PA/POR)
F-02118 Authorized Signer Designation for Access to PPS and FSIA
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-62440 Report of Hours Worked - Other Direct Care Nurse Aide / Day
F-01935 Wisconsin EMS First Responder Training Record - NCCP First Responder Refresher Requirements
F-60367 Community Advisory Committee Documentation
F-01735 CLIA Laboratory Test Methodology Report
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources
F-10115 BadgerCare Plus / Medicaid Health Insurance Information
F-44126 Antituberculosis Therapy Program Medication Refill Request
F-00311 Nursing Home MDS 3.0 Section Q Referral
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice
F-00165 Civil Rights Compliance Letter of Assurance
F-01182 Declaration of Supervision for Nonbilling Providers
F-00041 Asbestos Project Notification
F-01623 OARS - Residential Placement Reviews
F-00989G Tell Us About Your Family (IFSP)
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility
F-25207 Order Granting Capias
F-01219-pckt WISEWOMAN Assessment Packet
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers
F-01016 ForwardHealth Provider Suggestion
F-16023 Striker Evaluation
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators

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Last Revised: May 22, 2018