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.
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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 | Division | Other Location |
|---|---|---|---|
| F-10112 | Medicaid Disability Application | DMS | Other |
| F-00653 | Importing Procedure Records in NHSN (SSI DENOMINATOR) | DPH | None |
| F-80477A | Canteen Operations Analysis of Cash - GAAP Basis | DES | None |
| F-00024 | HSRS Core Summary Report | OS | None |
| F-44001 | Legal Notice: Required Immunizations for Admission to Wisconsin Schools | DPH | None |
| F-04003 | Vendor Monitoring Worksheet: Wisconsin WIC Program | DPH | None |
| F-02040 | WIC Program Notice of Categorical Ineligibility | DPH | None |
| F-44161A | WIC Cardholder Rights and Responsibilities | DPH | None |
| F-40096 | eWIC Program Repayment Agreement | DPH | None |
| F-02476A | Nurse Aide Federal Employment Eligibility Renewal: Employee Roster | DQA | None |
| F-82009II | WIC Confidential Information Release Authorization | DPH | Other |
| F-40059 | The Emergency Food Assistance Program (TEFAP) Eligibility Certification | DPH | None |
| F-45009 | Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices | DPH | None |
| F-45016 | Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope | DPH | None |
| F-44771B | Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-45006 | Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices | DPH | None |
| F-02011 | Fluoride Mouth Rinse Program Annual Report | DPH | None |
| F-45013 | Application for a Radioactive Material License Authorizing the Use of Industrial Radiography | DPH | None |
| F-45014 | Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators | DPH | None |
| F-45022 | Application for Material License | DPH | None |
| F-45010F | Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) | DPH | None |
| F-02530 | Application for Wisconsin's Test of English Proficiency (TEP) and Board for Examination of Interpreters (BEI) | DPH | None |
| F-45010A | Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) | DPH | None |
| F-45010B | Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) | DPH | None |
| F-45012 | Application for a Radioactive Material License for a Commercial Radiopharmacy | DPH | None |
| F-45010C | Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) | DPH | None |
| F-45010D | Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) | DPH | None |
| F-45007 | Certificate of Disposition of Materials | DPH | None |
| F-45010E | Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) | DPH | None |
| F-45008 | Application for Radioactive Material License for Medical Use | DPH | None |
| F-00740 | Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary | DQA | Other |
| F-62470 | Client/Patient/Resident Reportable Death Determination | DQA | None |
| F-45021 | Generally Licensed Device Inspection by Mail | DPH | None |
| F-01105 | Prenatal Care Coordination Pregnancy Questionnaire | DMS | None |
| F-01066 | HealthCheck Infant's Food Record (Birth to 12 Months of Age) | DMS | None |
| F-44771A | Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-22541 | Incident Report - Medicaid Waiver Programs | DMS | None |
| F-44771AA | Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning | DPH | None |
| F-01337 | Worksheet for Determination of Parental Payment Limit for CLTS | DMS | None |
| F-11029 | Prior Authorization / Chiropractic Attachment (PA/CA) | DMS | None |
| F-45015 | Application for Radioactive Material License for Broad Scope | DPH | None |
| F-62380 | Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application | DQA | None |
| F-05034 | Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. | DPH | Other |
| F-11036 | Prior Authorization / In-Home Treatment Attachment (PA / ITA) | DMS | None |
| F-01149 | Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements | DMS | None |
| F-11011 | Prior Authorization / Birth to 3 Attachment (PA/B3) | DMS | None |
| F-11103 | Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan | DMS | None |
| F-11044 | Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) | DMS | None |
| F-01066A | HealthCheck Child's Food Record / 1 to 12 Years of Age | DMS | None |
| F-62381 | Residential Care Apartment Complex (RCAC) Regulations Compliance Statement | DQA | None |
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Last Revised: March 26, 2019
