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-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-82018C Work Time Absence Record
F-02157 Nurse Aide Training Program – Application for Approval Checklist
F-16029 FoodShare Wisconsin Repayment Agreement
F-02035 Aging/ADRC Integration Funding Request Application
F-62496 Free-Standing Community-Based Residential Facility (CBRF) Plan Approval Application
F-13066 Claim Refund
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application
F-62027 Report of Hours Worked - Registered Nurse / Night
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds)
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36
F-10191 Medicaid Annuity Beneficiary Designation
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB)
F-01578A IRIS SharePoint - Request for User Setup
F-01751 Request for IMD Rebalancing Initiative Funding – Summary
F-01648 Coverdell Stroke Care Partner Agreement
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet
F-00989 Individualized Family Service Plan (IFSP)
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results
F-01812 Wisconsin Medicaid Program Nursing Home Cost Report
F-40019 Affirmation of Identity, Residency, and/or Income
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI)
F-01176 Prior Authorization Fax Cover Sheet
F-01459 Tuberculosis (TB) Program Dispensary Pre-Authorization for Non-Routine TB Services
F-62546 Corporate Guardianship Program Annual Report
F-21353 Community Options Program (COP) Exceptional Expense Request
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases
F-80900A Receivables Quarterly Report
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-62652 Home Health Agency Licensure Survey Home Visit Guide
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB)
F-00787 Prior Authorization - Requirement Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services
F-62322 Hospice Inpatient Clinical Record Review
F-21365 Comprehensive Community Services Startup Outcomes - 2009
F-01359 Historical Earnings Verification Request
F-02242 Hepatitis A High-Risk Occupations Questionnaire
F-80911 Limited Term Employment (LTE) or Project Employment Application
F-20810 Medicaid Waiver Program Health Report
F-62652A Personal Care Agency Home Visit Guide
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-62333 Plan Approval Application and Instructions
F-00565 County Performance Plan (CPP)
F-00417 AODA Prevention Services Recertification Application - DHS 75.04

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Last Revised: May 22, 2018