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-01205 IRIS Participant Education: Self-Direction Responsibilities
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting
F-01068G General Pediatric Clinic - 15 Month Visit
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-02282 Resident Relocation Roster
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information
F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents Renewal
F-80952A Contingency Plan - DHS Regional Offices
F-62654 Home Health Agency Licensure Survey Exit Conference Guide
F-16039 Waiver of Administrative Disqualification Hearing
F-13149 HIPAA Privacy Accounting Request
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan
F-00482 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Initial Certification Application - Chapter DHS 36
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys
F-11016 Prior Authorization Physician Attachment (PA/PA)
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
F-00233 Renewal Summary Letter
F-01931 Wisconsin EMS AEMT Training Record - AEMT Refresher Requirements
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure
F-45015 Application for Radioactive Material License for Broad Scope
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications
F-11018 Prior Authorization Request Form (PA/RF)
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months
F01454G IRIS Program Withdrawal Letter - Cancelled
F-62373 Resident Evacuation Assessment
F-00236 Request for a State Fair Hearing - MCO
F-01932 Wisconsin EMS EMT Training Record - EMT Refresher Requirements
F-60309 Self-Supervision Evaluation and Waiver Request
F-01721 Instructions-Calculating CLTS Foster Care Room and Board Expenses
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB)
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-01618 Client Services Agreement for Medicare Counseling
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP)
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA)
F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program
F-16021 Student Financial Aid Report
F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report
F-00681AL Family Care – Three (3) Managed Care Organization (MCO) Options (Large Print)
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions


Last Revised: May 22, 2018