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-01229 WISEWOMAN Provider Assurances and Training Checklist
F-21343A Alzheimer's Family and Caregiver Support Program (AFCSP) Financial Eligibility Screen - Worksheets 1 and 2
F-80751 Non-County Resident Proceedings Cost Certification
F-20572 Request for State Public Funding for Non-Residents
F-62610 Nurse Aide Training Program Primary Instructor Application
F-13470 Claim Form Attachment Cover Page
F-10097 Medicaid Income Allocation Notice
F-11318 Enrollment Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus
F-01349 Substitute Care Model Quality Performance Standards & Measures
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs
F-02193 Verifying Tax-Exempt Income for Live-In Care Providers
F-00059 Outpatient Mental Health Clinic Application - DHS 35
F-01165 Newborn Report
F-01744 Vaccine Restitution Policy - Agreement
F-62281 Care Level Change Notice
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-47463E Paramedic Operational Plan Components
F-11042 Prior Authorization Amendment Request
F-45008 Application for Radioactive Material License for Medical Use
F-44005 Visual Inspection of Registered Lead-Safe Property
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup
F-01481 Marriage Record Amendment Request Officiant Affidavit
F-40075 Pedometer Walking Program
F-00107W Self-Employment Income Report Worksheet
F-83292 Small Business Concern Feedback
F-21080 Children's Long-Term Support (CLTS) Waivers Eligibility Verification - Step One
F-10150A Your Rights and Responsibilities for Health Care
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees
F-00164 Civil Rights Compliance Plan
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-00042 Knowledge Journal
F-80115 Operating Budget
F-01989 Renewal Application – Individual Lead Disciplines
F-62520 Caregiver Program Compliance Check
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request
F-62092 Hospital Certificate of Approval Application
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services
F-47141 Emergency Medical Technician-Paramedic Training Permit Application
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-01105 PreNatal Care Coordination Pregnancy Questionnaire
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08


Last Revised: May 22, 2018