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
F-01312 IRIS Provider Application
F-25392 Petition for Re-Examination
F-81011 Cash Certification for Petty Cash, Canteen client / Resident and General Accounts
F-01668 Consent for Participation in Veterans Outreach and Recovery Program (VORP)
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure
F-01721 Instructions-Calculating CLTS Foster Care Room and Board Expenses
F-00335 Voluntary Agreement for Crisis Stabilization Services
F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System
F-00076 Variance Request - Wait List
F-00334 Money Follows the Person (MFP) - Participant Reporting
F-21353 Community Options Program (COP) Exceptional Expense Request
F-20946 Recertification Assurance--COP-W / CIP II
F-20980 Assessment / Supplement to the Long Term Care Functional Screen
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting
F-02036 Disaster Response Interpreter Training Application
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E)
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-01983 Self-Employment Income Worksheet: Business Capital Gains or Losses (Form 4797)
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-01812 Wisconsin Medicaid Program Nursing Home Cost Report
F-02046 IRIS Financial Projections Template
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer
F-01751 Request for IMD Rebalancing Initiative Funding – Summary
F-20415 CIP II Nursing Home Diversion Request Coversheet
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA)
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter
F-20394 CIP II Community Relocation Initiative 30-day / 90-day Questionnaire
F-01545 IRIS Fiscal Employer Agent (FEA) Biography
F-01655 Enrollment Discrepancy Report
F-01546 IRIS Consultant Agency (ICA) Biography
F-01319B IRIS Denial of Enrollment Request
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-01275A IRIS Provider Executive Staff Disclosure
F-01486 IRIS Consultant Biography
F-02035 Aging/ADRC Integration Funding Request Application
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist
F-01310 IRIS Program Conflict of Interest Disclosure – Provider
F-01310A IRIS Program Conflict of Interest Disclosure - Participant
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA)
F-01549 IRIS Certification Designation of Confidential and Proprietary Information
F-01352 Background Check Appeal Request - IRIS Program
F-01314 IRIS Program Employment Checklist
F-01319 IRIS Involuntary Disenrollment Request
F-01558 Risk Agreement – IRIS Program
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist

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Last Revised: May 22, 2018