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 Language
F-43026 Wisconsin Donor Registry User Access Request English
F-02040 WIC Program Notice of Categorical Ineligibility English
F-01204D Letter - IRIS Program Notice of Action--Termination English
F-05029 Request To Withdraw Voluntary Paternity Acknowledgement English
F-00015 Final Occupancy Inspection Checklist English
F-25527 Request for Increased Contract Allocation English
F-00193 Pediatric Referral / Communication Wisconsin WIC Program English
F-80025 Forms / Publications Order English
F-01208 IRIS Consultant Agency Quality Management Plan English
F-20822 County Review of Nursing Home, IMD or ICF/MR Referrals English
F-01646 AIDS/HIV Assistance and Insurance Assistance Program Insurance Enrollment Report (PDF, 193 KB) English
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification English
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail English
F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure (PDF, 171 KB) English
F-00479 Child Outcomes Fidelity Self-Assessment English
F-47204 Hazard Summary Form English
F-01556D IRIS Program Letter – Disenrollment English
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) English
F-00263 Personal Care Agency Record Review English
F-44063 Lead (Pb) Principal Instructor Application (PDF, 50 KB) English
F-62416 Community-Based Residential Facility – Initial Licensure Checklist English
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) English
F-05260 Letter of Non-Marriage Application English
F-00047 Designated Asbestos Coordinator (PDF, 39 KB) English
F-29323 Hardship Policy / Hidden Asset Policy (PDF, 17 KB) English
F-01578A IRIS SharePoint - Request for User Setup English
F-80751 Non-County Resident Proceedings Cost Certification English
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment English
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution English
F-01628 OARS Enrollment Letter English
F-00922 Behavioral Health Integrated Care Health Home Certification Application English
F-62457 Request for Permission to Start Construction for Footings and Foundations English
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure (PDF, 178 KB) English
F-00537 CSAS Intervention Services Initial Certification Application - DHS 75.16 English
F-47255 Emergency Medical Services Funding Assistance Program Municipal Signature and Population Verification Page English
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) English
F-00315A Written Prior Notice - No Evaluation Recommended English
F-44621 WIC Stock Price Survey English
F-02167 Program Participation System (PPS) PORTAL Report Feedback English
F-01442 IRIS Disenrollment Letter - Death English
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice English
F-00076 Variance Request - Wait List English
F-40063 The Emergency Food Assistance Program (TEFAP) Commodities Complaint English
F-01949 ADRC Annual Update English
F-80952A Contingency Plan - DHS Regional Offices English
F-01285 Quarterly MCO Consolidated Financial Report Template - Model English
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI English
F-01622 OARS Records Checklist English
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet English
F-01205P IRIS Participant Education: Background Check Process English

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Last Revised: July 28, 2017