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-62281 Care Level Change Notice
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement
F-62224 Nurse Aide Training Program – Notice of Substantial Change
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-01442i IRIS Program Disenrollment Letter - Cancelled
F-01319C IRIS Program – Denial of Enrollment Letter
F-01454E IRIS Program Withdrawal Letter – Voluntary
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-01442G IRIS Program Disenrollment Letter – Non-Spending
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-01468 IRIS Program Start Date Letter – New Participant
F-01442 IRIS Disenrollment Letter - Death
F-01204D Letter - IRIS Program Notice of Action - Termination
F-01942A LTC FS - Diagnosis Verification Letter
F-01454 IRIS Program Withdrawal Letter – No Progress
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility
F-01204E Letter - IRIS Program Notice of Action - Functional Eligibility
F-01942B LTC FS - Request Letter
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen
F01454G IRIS Program Withdrawal Letter - Cancelled
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility
F-01942C LTC FS - Release of Information Authorization
F-01454B IRIS Program Withdrawal Letter – Health and Safety
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter
F-01442C IRIS Program Disenrollment Letter – No Contact
F-01942D LTC FS - Change in Condition - Release of Information Authorization
F-01454C IRIS Program Withdrawal Letter – No Contact
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting
F-01454F IRIS Program Withdrawal Letter - Death
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting
F-01204B Letter - IRIS Program Notice of Action - Limit
F-00565 County Performance Plan (CPP)
F-00565A County Performance Plan (CPP) Goals
F-01204A Letter - IRIS Program Notice of Action - Denial
F-25615 Supervised Release Rules
F-02209 Program Integrity Annual Survey – Health Maintenance Organizations (HMOs)
F-80025 Forms / Publications Order
F-44815 Immunization Program Orders (Medical Authorization), Policy and Procedure Approval, and Indemnification
F-11285 HealthCheck Screener Affirmation


Last Revised: May 22, 2018