Forms Library

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
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-00978 Confirmation of Confidential Data Destruction - Wisconsin Cancer Reporting System (WCRS) DPH
F-02778 Community-Based Vaccination Clinic Request for Dedicated Vaccine Supply CRT
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-21076 Informed Consent – Children's Long-Term Support Functional Screen DMS
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS
F-02522 Supervised Release Individual Client Summary DCTS
F-01885 Requesting State Trauma Registry Access DPH
F-01684 Community Mental Health Allocation (CMHA) Report DCTS
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-62062 Hospice License Application DQA
F-10098 Medicaid Member Asset Allocation DMS
F-00974 Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor DPH
F-10101 Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet DMS
F-02720A Family Caregiver Support Program Post Evaluation DPH
F-02720 Family Caregiver Support Program Initial Evaluation DPH
F-00046 Family Care Program — Enrollment DPH
F-02483 PACE Program Enrollment DPH
F-00533 Partnership Programs — Enrollment DPH
F-02053 ADRC Referral to Income Maintenance for Managed Long-Term Care Services DPH
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit DMS
F-00388 County Birth to 3 Fiscal Reconciliation Report DMS
F-25207 Order Granting Capias DCTS
F-10097 Institutional Medicaid Income Allocation DMS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS
F-10097A Community-Based Long-Term Care Services Medicaid Income Allocation DMS
F-25177 Statement of Probable Cause and Detention and Petition for Revocation DCTS
F-25180 Order of Discharge Upon Expiration of Commitment DCTS
F-25206 Petition for Capias DCTS
F-02733 Request for Community Spouse Signature DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions DPH
F-21334 Encounter New User Request DMS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-44126 Antituberculosis Therapy Program Medication Refill Request DPH
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-02764 Participant Fiscal Employer Agent (FEA) – Transfer Request DPH
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS
F-16019A FoodShare Wisconsin Registration DMS
F-02022 Claims Audit Report for Managed Long-Term Care MCOs DMS

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Last Revised: March 23, 2021