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-01307 Medicaid Purchase Plan (MAPP) Eligibility Worksheet DMS
F-02388 MIPPA Grant Agency Application DPH
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-01454F IRIS Program Withdrawal Letter – Death DMS
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F01454G IRIS Program Withdrawal Letter – Cancelled DMS
F-02605 Home and Community-Based Services (HCBS) Settings Rule DMS
F-16026 Prosecution Diversion Agreement DMS
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-44161 WIC Rights and Responsibilities DPH
F-40044 Participant Agreement, Rights & Responsibilities DPH
F-02491 FoodShare Buy and Make Food Separately DMS
F-16028 Notice of FoodShare Overissuance DMS
F-40085 WIC Program Notice of Ineligibility DPH
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-16038 Administrative Disqualification Hearing Notice DMS
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program DMS
F-02431 Statement About U.S. Military Service DMS
F-44764 Do Not Resuscitate Bracelet - Electronic Format DPH
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-40096 eWIC Program Repayment Agreement DPH
F-40028 Participant Determination Letter DPH
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-16024 FoodShare Notice of Disqualification DMS
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-16025 Disqualification Consent Agreement DMS
F-10114 Medicaid Disability Redetermination Report DMS
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-02603 Request for a Temporary Waiver of MAPP Premium DMS
F-01542 Notification of Required Drug Testing DMS
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification DPH
F-02700 Wisconsin COVID-19 Patient Information DPH
F-00036 Power of Attorney for Finance and Property DPH
F-10137 Medicaid Change Report DMS
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement DPH
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-22541 Incident Report – IRIS DMS
F-62062 Hospice License Application DQA
F-62680 Home Health Agency (HHA): Clinical Record Review (State Only) DQA
F-62231 Home Health Agency Personnel Record Review DQA
F-62680A Home Health Agency (HHA): Clinical Record Review (State & Federal) DQA
F-62674 Home Health Agency License Application DQA
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-80025 Forms / Publications Order OS
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training DPH

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Last Revised: March 26, 2019