Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Location
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS
F-00615 Change Project Report and Instructions DPH
F-00726 Typical Vision Developmental Milestones DMS
F-00321 OBVI Initial Interview Assessment DPH
F-00676 Youth Transition Pretest DPH
F-00315 Written Prior Notice DMS
F-00390 Incident Report - Community Recovery Services (CRS) DCTS
F-00727 Typical Hearing Developmental Milestones DMS
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS
F-00676A Youth Transition Post-Test DPH
F-00043 Communication to Local Educational Agency Regarding Child Referral DMS
F-00315A Written Prior Notice - No Evaluation Recommended DMS
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
F-00777 MAPT Vendor Related Allocation Formula DMS
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application DCTS
F-00889 Designation of Confidential and Proprietary Information - Managed LTC Business Plan DMS
F-02529 Accreditation Mentoring Program - Mentee Application DPH
F-02528 Accreditation Mentoring Program - Mentor Application DPH
F-05102 Wisconsin Immunization Registry Opt-out Request DPH
F-02505 Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS
F-02524 Agent Training Request DCTS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-02106C Adult Day Care Center – New Provider Certification Application DQA
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement DPH
F-00191 Certified Outpatient Clinic: Request for a Branch Office DQA
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-00588 PPS Alcohol and Other Drug Abuse Module DCTS
F-00596 PPS Mental Health Module DCTS
F-00685 Statement of Tribal Affiliation DMS
F-00367B Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00101 Authorization to Request Birth Records DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-00098 Summary of Information Letter DMS
F-00154 Wisconsin Consultative Examination Inquiry DMS
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report DPH
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-02495 Vaccine for Adults (VFA) Provider Agreement DPH
F-02288 WisCaregiver Career Program: Registration Agreement DQA
F-00407 Financial Records Request DMS
F-20942A Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet OPIB
F-02034 Aging/ADRC Integration Funding Budget Worksheet DPH
F-42016 Authorization for Release of Confidential HIV Test Results DPH
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS

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Last Revised: March 23, 2021