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-11129B-H Wisconsin Medicaid - Federally Qualified Health Center Cost Report Forms English
F-01013 Nurse Aide Training and Competency Test Reimbursement Request English
F-01067 HealthCheck Your Child's Speech and Hearing English
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice English
F-01008 Wisconsin Medicaid - Notification of Hospice Benefit Election English
F-11047 Wisconsin Medicaid - Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 (PDF, 24 KB) English
F-00142 Prior Authorization / Drug Attachment for Synagis English
F-13066 Claim Refund English
F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus (PDF, 45 KB) English
F-01009A Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under English
F-11048 Wisconsin Medicaid - Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission (PDF, 29 KB) English
F-13074 Pharmacy Special Handling Request English
F-01009B Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older English
F-01176 Prior Authorization Fax Cover Sheet English
F-01161 Abortion Certification Statements English
F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers English
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan English
F-10154 Statement of Identity for Children Under 18 Years of Age English
F-01002 HealthCheck Individual Health History English
F-80952A Contingency Plan - DHS Regional Offices English
F-82021 Researcher's Request for Confidential Records or Human Subjects Research (PDF, 14 KB) English
F-82003 Denial of Researcher Access To Health Care Records (PDF 14 KB) English
F-80751 Non-County Resident Proceedings Cost Certification English
F-80911 Limited Term Employment (LTE) or Project Employment Application English
F-69307 Kitchen / Food Service Observation CMS-804 English
F-80952 Contingency Plan - Health and Human Services Agencies English
F-82002 Denial of Government Access To Health Care Records (PDF, 13 KB) English
F-62680 Home Health Agency Clinical Record Review English
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide English
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs English
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report English
F-62654 Home Health Agency Licensure Survey Exit Conference Guide English
F-62569 Individual Provider Status Approval Application and Supervisor Affidavit English
F-62092 Hospital Certificate of Approval Application English
F-62595 Long-term Care Facility Feeding Assistant Roster English
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail English
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request English
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) English
F-62369 Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF) English
F-47479 Trauma Care Facility Classification Application English
F-62651A Personal Care Agency Calendar Worksheet - Prescribed Visits English
F-47208 Recreational / Educational Camp Inspection Report English
F-62520 Caregiver Program Compliance Check English
F-60309 Self-Supervision Evaluation and Waiver Request English
F-62652 Home Health Agency Licensure Survey Home Visit Guide English
F-62674A Model Balance Sheet English
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation English
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) English
F-45022 Application for Material License English
F-45023 Certificate - Use of Depleted Uranium under General License (PDF, 308 KB) English

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Last Revised: July 28, 2017