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-83292 Small Business Concern Feedback
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet
F-00024 HSRS Core Summary Report
F-01421 WISEWOMAN Monthly Reporting for Direct Services
F-01359 Historical Earnings Verification Request
F-80477 Canteen Operations Statement of Revenues / Expenses and Fund Equity Changes - GAAP Basis
F-80477A Canteen Operations Analysis of Cash - GAAP Basis
F-80477B Canteen Operations Balance Sheet - GAAP Basis
F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan
F-47247 Ambulance Attendant License/Permit Renew
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-80115 Operating Budget
F-80122 Journal Voucher
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-21231 County Agency Contacts Regarding Children at MMHI / WMHI
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY)
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB)
F-00917 Provider Enrollment Application Process
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency
F-40058 Verification of Transfer of USDA Commodities
F-80952 Contingency Plan - Health and Human Services Agencies
F-80952A Contingency Plan - DHS Regional Offices
F-00191A Certified Outpatient Clinic Request for a School Branch Office
F-44089 Wisconsin WIC Checks Accepted Here - Stickers
F-00233 Renewal Summary Letter
F-00923 Reschedule Lead (PB) Certification Exam (PDF, 90 KB)
F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey
F-01320 Lead Test Kit Documentation
F-45038 Wisconsin Mercury Exposure Study
F-05027A Report of Citizenship
F-69312 Surveyor Notes Worksheet CMS-807
F-00553 Professional & Occupational License Application & Affidavit
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research
F-47477 First Responder / Emergency Medical Technician Certificate / License
F-05098 Court Order to Correct Facts, Misrepresented Information
F-80462 Capital Asset Summary
F-05021C Report of Legal Name Change - Confidential
F-01215 National CLAS Standards Pledge
F-62296 Entrance Conference Checklist
F-47181 First Responder Certification Card
F-00653a Patient Data Import Training
F-05043 Notice of Removal - Corpse (Hospital, Nursing Home, Hospice)
F-62504 Community Substance Abuse Services (CSAS) or Mental Health Clinic Initial Certification Application
F-01112 HealthCheck Verification Card
F-47020 Sink Requirements
F-12029 Managed Care Disenrollment Request
F-05027B Report of Naturalization

Pages

Last Revised: May 22, 2018