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-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Providers
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center
F-01279 Program Participation System (PPS) Employment Interview
F-21334 Encounter New User Request
F20418 Agency Application for Access to Web-Based Personal Care Screening Tool
F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671
F-16019A FoodShare Wisconsin Registration
F-02000 ADRC/Aging System User: Access/Delete/Change
F-62157 Living Unit Direct Care Staff Report - Evening Shift
F-00759 Business Associate Agreement - With Contract
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA)
F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive)
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09
F-01556 Medicaid Cost Share Letter - Initial
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application
F-42000 Vaccine Order
F-02410 Voluntary Property Checklist for Child Care Providers
F-00236A Request for a State Fair Hearing - ADRC
F-01402 Test Your Knowledge About Trauma-Informed Care
F-01332 Predispositional Investigation Report (PDI)
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet
F-01729 Nonprobate Asset / Property Disclosure
F-00020 Drug Addition Review Request
F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2
F-01165 Newborn Report
F-16038 Administrative Disqualification Hearing Notice
F01454G IRIS Program Withdrawal Letter - Cancelled
F-62316 Hospice Patient Rights
F-00889 Designation of Confidential and Proprietary Information - Managed LTC Business Plan
F-00681EEE IRIS (Include, Respect, I Self-Direct) Fiscal Employer Agent (FEA) Options
F-11285 HealthCheck Screener Affirmation
F-45023 Certificate - Use of Depleted Uranium under General License
F-00515 Community Substance Abuse Services (CSAS) Day Treatment Service Initial Certification Application - DHS 75.12
F-01571 Air Quality Measurement Device Maintenance and Calibration Log
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records
F-01430 Prior Authorization Drug Attachment for Xyrem®
F-04002 School Report to Local Health Department
F-22688 Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide
F-02258 Minority Health Advisory Committee Application
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s)
F-80900 Receivables Annual Report
F-01199 Optional School-Based Services Activity Medication Administration
F-20445A Individual Service Plan - Individual Outcomes
F-02050 Coordinated Services Teams (CST) Final Expenditure Report
F-62461 Application for Critical Access Hospital Certification of Approval
F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet

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Last Revised: May 22, 2018