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 Locationsort descending
F-62441 Report of Hours Worked - Other Direct Care Nurse Aide / Evening
F-01012 Reimbursement Request for a PASRR Level I Screen
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35
F-11306 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-00553 Professional & Occupational License Application & Affidavit
F-00407 Financial Records Request
F-60945 Adult Family Home Initial Licensure Application
F-00309 Medicaid Provider Report
F-00193 Pediatric Referral / Communication Wisconsin WIC Program
F-60953 Adult Family Home Fire Safety Guide
F-01622 OARS Records Checklist
F-01590 MCO Letter – Notice of Change in Level of Care
F-11042 Prior Authorization Amendment Request
F-44819 Farmers Market Nutrition Program (FMNP) - Application for Farmstands
F-10150B Your Rights and Responsibilities for FoodShare
F-44000 Tuberculosis Disease Initial Request for Medication
F-01319 IRIS Involuntary Disenrollment Request
F-00166 Service Delivery or Employment Discrimination Complaint
F-01557 Pool and Water Attractions Operator Survey
F-01398 WISEWoman Client Home Blood Pressure Monitoring Agreement
F-40071 Children's Physical Activity Chart
F-01223 WISEWOMAN Case Management
F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate
F-80476 Asset Transfer
F-21076 Informed Consent - Children's Long-Term Support Functional Screen
F-01118 Child Care Coordination Family Questionnaire
F-16073 FoodShare Wisconsin Nonfinancial Worksheet
F-00963 Children’s Long Term Support Reconciliation Packet
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-01558 Risk Agreement – IRIS Program
F-01430 Prior Authorization Drug Attachment for Xyrem®
F-40072 8 Week Activity Log
F-01224 WISEWOMAN Healthy Behavior Initial Support
F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment
F-80477 Canteen Operations Statement of Revenues / Expenses and Fund Equity Changes - GAAP Basis
F-21077 Autism Treatment Services Criteria Checklist Instructions
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit
F-16076 FoodShare Six-Month Report and Instructions
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center
F-00059 Outpatient Mental Health Clinic Application - DHS 35
F-00676A Youth Transition Post-Test
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04
F-02110 Residential Care Apartment Complex (RCAC)
F-44215 Child Care Center Report to the District Attorney
F-62643 Drug Repository Program Notice of Participation or Withdrawal
F-01949 ADRC Annual Update
F-62296 Entrance Conference Checklist
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs
F-11237 Specialized Medical Vehicle Provider Affidavit


Last Revised: July 28, 2017