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-00628 Consortium Response to the State IM Second Party Review Finding
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-02167 Program Participation System (PPS) PORTAL Report Feedback
F-80115 Operating Budget
F-02046 IRIS Financial Projections Template
F-62588 Feeding Assistant Training Program Application
F-01748 Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-16029 FoodShare Wisconsin Repayment Agreement
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day
F-13066 Claim Refund
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA)
F-00480 Child Outcomes Summary
F-11008 Prior Authorization / Therapy Attachment (PA/TA)
F-00366 Wisconsin Adult Long-Term Care Functional Screen
F-00232 Notice of Action - MCOs
F-01761 Intoxicated Driver Program Self-Evaluation
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter
F-00161 Caregiver Misconduct Reporting Requirements Worksheet
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services
F-29315 Instructions: Declaration of Income and Assets and State Residency
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment
F-01186 Wisconsin Chronic Renal Disease Program Application
F-01018 Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers
F-01204D Letter - IRIS Program Notice of Action - Termination
F-02242 Hepatitis A High-Risk Occupations Questionnaire
F-80962 New Capital Asset Record
F-62416 Community-Based Residential Facility – Initial Licensure Checklist
F-21343E Alzheimer's Family and Caregiver Support Program (AFCSP) General Information
F-62696 Student Nurse / Graduate Nurse Verification
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-62470 Client / Patient / Resident Death Determination
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB)
F-00842 Pharmacy Services Lock-In Program - Program Summary
F-00569 Request for Waiver of Administrative Rule for Licensure
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05
F-00315A Written Prior Notice - No Evaluation Recommended
F-01454F IRIS Program Withdrawal Letter - Death
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-62025 Report of Hours Worked - Registered Nurse / Evening
F-01710 Home Health Agency Initial Licensure Checklist
F-01604 Telehealth Application – Annual Review of Approval
F-00101 Authorization to Request Birth Records
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding
F-44010 Lead-Free / Lead-Safe Property Registry, Training Course, Class and Roster Database Access Application
F-05281 Wisconsin Marriage Certificate Application
F-40075 Pedometer Walking Program

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Last Revised: July 28, 2017