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 Division Other Location
F-02544 Nursing Home Immediate Jeopardy (IJ) Removal Plan DQA
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH
F-00047 Designated Asbestos Coordinator DPH
F-01999B Senior Companion Program: State Match Funding Application DPH
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-00905 Tuberculosis Infection (LTBI) Initial Request for Medication DPH
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-00053 Notice of Intent to Submit an Application (ADRC) DPH
F-02541 Wisconsin Birth Defects Condition Nomination DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-02069 DHS Quarterly Report on Consumers Enrolled in CCS DCTS
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application DPH
F-02000 ADRC/Tribal ADRS/Aging System User: Access/Delete/Change DPH
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application DPH
F-00576A Tribal Aging and Disability Resource Specialist (TADRS) Annual Budget DPH
F-01398 WISEWOMAN Client Home Blood Pressure Monitoring Agreement DPH
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-44444 WIC Vendor Supply Order DPH
F-22565 Authorization for Recoupment Caretaker Supplement DMS
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS
F-11271 Personal Care Provider Addendum DMS
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-00567 Emergency Medical Services Complaint DPH
F-11240 Case Management Provider Information OIG
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research DMS
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-11245 Family Planning Clinics or Agencies OIG
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-11129B-H Federally Qualified Health Center Cost Report Forms OIG
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation DPH
F-82018C Work Time Absence Record DES
F-20812 SSI-E Natural Residential Setting Application Checklist DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-11260 Degree Addendum OIG
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-02538A CLTS Provider Cost-Based Outlier DMS
F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease DMS
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-44819 Farmers Market Nutrition Program (FMNP) - Application for Farm Stand DPH
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS
F-47479 Trauma Care Facility Classification Application DPH
F-11022 Rural Health Clinic Statistical Data DMS
F-47470 Change of EMS Medical Director DPH
F-02538 Children’s Long-Term Support Waiver Program—Outlier Rate Request DMS
F-01359 Historical Earnings Verification Request DMS
F-01161 Abortion Certification Statements DMS


Last Revised: March 26, 2019