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-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application
F-01814 County Agency Children’s Community Options Program (CCOP) Five-Year Plan
F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports
F-21225 Program Participation System (PPS): B-3 Module
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bedhold Days
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary
F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report
F-21284 Clinician Confirmation of Diagnosis
F-00539 Children's Long Term Support Service Coordination Rate Worksheet
F-01798 Retroactive Overtime To Be Calculated
F-01769 TEFAP Soup Kitchen Self-Assessment
F-01767 TEFAP Shelter Self-Assessment Tool
F-01710 Home Health Agency Initial Licensure Checklist
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire
F-01930 Minority Health Advisory Group Nomination and Agreement
F-62579 Post Survey Questionnaire
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO
F-01623 OARS - Residential Placement Reviews
F-01625 OARS Participant Discharge Summary
F-01621 Smoking Cessation Data Collection
F-01627 OARS Provider Case Manager Checklist
F-20572 Request for State Public Funding for Non-Residents
F-01682 Wisconsin State Certified Peer Specialist Trainer Application
F-01681 Comprehensive Community Services (CCS) Technical Assistance Survey
F-01336 Wisconsin Assessment of the Impaired Driver (WAID) and Other Substance Users
F-20389 DCTS Program Performance Report
F-01761 Intoxicated Driver Program Self-Evaluation
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s)
F-01341 Pre-Release from Institution Checklist (CM Checklist)
F-01601B ISP Line Item Detail Budget
F-01332 Predispositional Investigation Report (PDI)
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs
F-01345 Special Care Environment Working Document
F-01346 Behavior Monitoring Record-Model
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-00202 Individual Service Plan - Community Recovery Services (CRS)
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-00660A Client Rights Office Consult Question
F-00085 Power of Attorney for Health Care
F-00060 Declaration to Physicians (Living Will)
F-01628 OARS Enrollment Letter
F-00059 Outpatient Mental Health Clinic Application - DHS 35
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS)
F-01735 CLIA Laboratory Test Methodology Report
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC


Last Revised: May 22, 2018