Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.
| Assigned Number | Title | Division | Other Location |
|---|---|---|---|
| F-02573 | Prior Authorization Drug Attachment for Wakix | DMS | None |
| F-11318 | Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus | OIG | None |
| F-01468 | IRIS Program Start Date Letter – New Participant | DMS | None |
| F-01468A | IRIS Program Start Date Letter – Transferring Participant | DMS | None |
| F-00978 | Confirmation of Confidential Data Destruction - Wisconsin Cancer Reporting System (WCRS) | DPH | None |
| F-02778 | Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply | CRT | None |
| F-12026 | Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request | DMS | Other |
| F-02487 | Wisconsin Immunization Registry (WIR) Record Release Authorization | DPH | None |
| F-21076 | Informed Consent – Children's Long-Term Support Functional Screen | DMS | None |
| F-02766 | Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members | DMS | None |
| F-02522 | Supervised Release Individual Client Summary | DCTS | None |
| F-01885 | Requesting State Trauma Registry Access | DPH | None |
| F-01684 | Community Mental Health Allocation (CMHA) Report | DCTS | None |
| F-00251 | Mental Health Block Grant Community Aids Allocation Report | DCTS | None |
| F-62062 | Hospice License Application | DQA | None |
| F-10098 | Medicaid Member Asset Allocation | DMS | None |
| F-00974 | Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor | DPH | None |
| F-10101 | Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet | DMS | Other |
| F-02720A | Family Caregiver Support Program Post Evaluation | DPH | None |
| F-02720 | Family Caregiver Support Program Initial Evaluation | DPH | None |
| F-00046 | Family Care Program — Enrollment | DPH | None |
| F-02483 | PACE Program Enrollment | DPH | None |
| F-00533 | Partnership Programs — Enrollment | DPH | None |
| F-02053 | ADRC Referral to Income Maintenance for Managed Long-Term Care Services | DPH | None |
| F-01058 | Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit | DMS | None |
| F-00388 | County Birth to 3 Fiscal Reconciliation Report | DMS | None |
| F-25207 | Order Granting Capias | DCTS | None |
| F-10097 | Institutional Medicaid Income Allocation | DMS | None |
| F-10151 | Medicaid / BadgerCare Plus Fair Hearing Information | DMS | None |
| F-10097A | Community-Based Long-Term Care Services Medicaid Income Allocation | DMS | None |
| F-25177 | Statement of Probable Cause and Detention and Petition for Revocation | DCTS | None |
| F-25180 | Order of Discharge Upon Expiration of Commitment | DCTS | None |
| F-25206 | Petition for Capias | DCTS | None |
| F-02733 | Request for Community Spouse Signature | DMS | None |
| F-01567 | Long-Term Care Insurance Policy – Assignment of Benefits | DMS | None |
| F-44614I | AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions | DPH | None |
| F-21334 | Encounter New User Request | DMS | None |
| F-16030 | FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator | DMS | None |
| F-40108 | Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program | DPH | None |
| F-44126 | Antituberculosis Therapy Program Medication Refill Request | DPH | None |
| F-13509 | Wisconsin Well Woman Program Provider Certification | OIG | None |
| F-00534 | Partnership Member Requested Disenrollment or Transfer and Instructions | DPH | None |
| F-00221 | Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions | DPH | None |
| F-02484 | Pace Program Member Requested Disenrollment or Transfer Instructions | DPH | None |
| F-00075 | IRIS (Include, Respect, I Self-Direct) Authorization | DPH | None |
| F-02404 | Family Care, Partnership, PACE, or IRIS Change Routing Instructions | DPH | None |
| F-02764 | Participant Fiscal Employer Agent (FEA) – Transfer Request | DPH | None |
| F-02717 | Electronic Visit Verification (EVV) Live-in Worker Identification | DMS | None |
| F-16019A | FoodShare Wisconsin Registration | DMS | Other |
| F-02022 | Claims Audit Report for Managed Long-Term Care MCOs | DMS | None |
Pages
Last Revised: March 23, 2021
