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-21353 Community Options Program (COP) Exceptional Expense Request
F-02036 Disaster Response Interpreter Training Application
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-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
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-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-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request
F-20415 CIP II Nursing Home Diversion Request Coversheet
F-01751 Request for IMD Rebalancing Initiative Funding – Summary
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care
F-20394 CIP II Community Relocation Initiative 30-day / 90-day Questionnaire
F-01655 Enrollment Discrepancy Report
F-01545 IRIS Fiscal Employer Agent (FEA) Biography
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-01546 IRIS Consultant Agency (ICA) Biography
F-01319B IRIS Denial of Enrollment Request
F-02035 Aging/ADRC Integration Funding Request Application
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist
F-01486 IRIS Consultant Biography
F-01275A IRIS Provider Executive Staff Disclosure
F-01319 IRIS Involuntary Disenrollment Request
F-01310 IRIS Program Conflict of Interest Disclosure – Provider
F-01558 Risk Agreement – IRIS Program
F-01310A IRIS Program Conflict of Interest Disclosure - Participant
F-01352 Background Check Appeal Request - IRIS Program
F-01549 IRIS Certification Designation of Confidential and Proprietary Information
F-01314 IRIS Program Employment Checklist
F-01282 Monthly Enrollment Discrepancy Report Template - Model
F-01210A IRIS Budget Amendment Provider Quote Comparison
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-01240 IRIS Critical Incident Reconciliation
F-01246 Background Information Disclosure Addendum—IRIS
F-01275 IRIS Provider Board Member Disclosure
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-01287 Template for Transition - Initial Plan - Model
F-01278 Program Participation System (PPS) Employment Questions
F-01279 Program Participation System (PPS) Employment Interview
F-00539A General Support and Service Coordination Rate Certification Worksheet
F-01206 IRIS One-Time Expense Request
F-01207A IRIS Fiscal / Employer Agent Quality Management Plan Tracking
F-01206B IRIS One-Time Expense Request - Ramp
F-01208A IRIS Consultant Agency Quality Management Plan Tracking

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Last Revised: May 22, 2018