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-01204A | Letter – IRIS Program Notice of Action – Denial | DMS | None |
| F-01204B | Letter – IRIS Program Notice of Action – Limit | DMS | None |
| F-02383 | HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary | DMS | None |
| F-02721 | Notice of Adverse Benefit Determination | DPH | None |
| F-80025A | Forms / Publications Order | OS | None |
| F-01203 | IRIS Provider Education – Health and Safety – Incident Reporting | DMS | None |
| F-00236A | Request for a State Fair Hearing - ADRC | DPH | None |
| F-02390 | Fall Medicare Training Participant Survey | DPH | None |
| F-02743 | Application Telecommunications Assistance Program Hearing Aid Assistance (TAP HAA) | DPH | None |
| F-44019A | Immunization Assessment | DPH | None |
| F-40093 | Annual ROSIE User Security and Confidentiality Agreement | DPH | None |
| F-00004 | Health and Employment Counseling Application | DMS | None |
| F-02306 | Application for Telecommunication Assistance Program (TAP) | DPH | None |
| F-02759 | Comprehensive Community Services Cost Settlement Advance Request | DMS | None |
| F-62457 | Request for Permission to Start Construction for Footings and Foundations | DQA | None |
| F-19002 | Request to Reduce QUEST Card Balance | DMS | None |
| F-02476A | Nurse Aide Federal Employment Eligibility Renewal: Employee Roster | DQA | None |
| F-00950 | Partnership Coverage Decision Letter | DMS | None |
| F-02463 | Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement | DPH | None |
| F-11129A | Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions | DMS | None |
| F-11129B-H | Tribal and Out-of-State Federally Qualified Health Center Cost Report Forms | OIG | None |
| F-11130 | Tribal and Out-of-State Federally Qualified Health Center Interim Report | DMS | None |
| F-02758 | Federally Qualified Health Center Outstationed Enrollment Survey | OIG | None |
| F-02656 | Federally Qualified Health Center Cost Report | DMS | None |
| F-00401 | Preferred Drug List Expedited Emergency Supply Request | DMS | None |
| F-01430 | Prior Authorization Drug Attachment for Xyrem and Xywav | DMS | None |
| F-00163 | Prior Authorization / Drug Attachment for Anti-Obesity Drugs | DMS | None |
| F-01950 | Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis | DMS | None |
| F-00805 | Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators | DMS | None |
| F-00888 | ADRC Action Plan | DPH | Other |
| F-22554 | Hearing Loss Certification Telecommunications Assistance Program (TAP) | DPH | None |
| F-02476 | Nurse Aide Federal Employment Eligibility Renewal Waiver Request | DQA | None |
| F02761 | Health Care Entity Staffing Request | DPH | None |
| F-02721A | Notice of Delay in Functional Eligibility Determination | DPH | None |
| F-02721B | Notice of Medical Remedial Expenses | DPH | None |
| F-20582 | Medicaid – Katie Beckett Program Application | DMS | None |
| F-02746 | Request for Institution of Mental Disease Determination for Residential Substance Use Disorder Facilities | DMS | None |
| F-02067 | Women, Infants, and Children (WIC) Staff Training Record | DPH | None |
| F-10150A | Your Rights and Responsibilities for Health Care | DMS | None |
| F-40019 | Affirmation of Identity, Residency, Income, or Benefit Loss | DPH | None |
| F-44621 | WIC Stock Price Survey | DPH | None |
| F-04003 | Vendor Monitoring Worksheet: Wisconsin WIC Program | DPH | None |
| F-44323 | WIC Stock Price Survey – Pharmacy Only | DPH | None |
| F-02567 | Prior Authorization / Residential Substance Use Disorder Treatment Attachment (PA/RSUD) | DMS | None |
| F-02500 | Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care | DPH | None |
| F-00950A | Notice of Denial of Medical Coverage – PACE | DMS | None |
| F-01938 | Wisconsin EMS Paramedic Training Record - NCCP Paramedic Refresher Requirements | DPH | None |
| F-01954 | Wisconsin EMS Training Record NCCP AEMT Refresher Requirements | DPH | None |
| F-20985 | Participant Rights and Responsibilities Notification | DMS | None |
| F-01955 | Wisconsin EMS Training Record Critical Care Paramedic Refresher Record | DPH | None |
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Last Revised: March 23, 2021
