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-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan
F-47482 Emergency Medical Service Training Center Certification Application (PDF, 84 KB)
F-47463A First Responder Operational Plan Components (PDF, 19 KB)
F-47463B Emergency Medical Techician (EMT) - Basic Operational Plan Components (PDF, 26 KB)
F-47463C Emergency Medical Techician (EMT) - Intermediate Technician Operational Plan Components (PDF, 721 KB)
F-47247 Ambulance Attendant License/Permit Renew
F-47463D Emergency Medical Techician (EMT) - Intermediate Operational Plan Components (PDF, 26 KB)
F-82009 Confidential Information Release Authorization - Generic 
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-80115 Operating Budget
F-80122 Journal Voucher
F-80761 Contingent Account Activity Report
F-80015 Summary of Depository Funds Annual Report
F-80459 Client Account Balance Report
F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2
F-44771AA Medicaid Targeted Case Management Face Sheet - Childhood Lead Poisoning
F-00020 Drug Addition Review Request
F-62019 License Application for Nursing Home, Intermediate Care Facility – Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD)
F-62155 Living Unit Census Report
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI
F-80130 Financial Information 
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY)
F-00917 Provider Enrollment Application Process
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB)
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency
F-40058 Verification of Transfer of USDA Commodities
F-80751 Non-County Resident Proceedings Cost Certification
F-80952 Contingency Plan - Health and Human Services Agencies
F-69307 Kitchen / Food Service Observation CMS-804
F-82002 Denial of Government Access To Health Care Records (PDF, 13 KB)
F-80952A Contingency Plan - DHS Regional Offices
F-82021 Researcher's Request for Confidential Records or Human Subjects Research (PDF, 14 KB)
F-82003 Denial of Researcher Access To Health Care Records (PDF 14 KB)
F-80911 Limited Term Employment (LTE) or Project Employment Application
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
F-62369 Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF)
F-47208 Recreational / Educational Camp Inspection Report
F-47479 Trauma Care Facility Classification Application
F-62651A Personal Care Agency Calendar Worksheet - Prescribed Visits
F-62520 Caregiver Program Compliance Check
F-60309 Self-Supervision Evaluation and Waiver Request
F-62652 Home Health Agency Licensure Survey Home Visit Guide
F-62674A Model Balance Sheet
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
F-62680 Home Health Agency Clinical Record Review
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report

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Last Revised: July 28, 2017