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-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) English
F-00262 Personal Care Agency Application Materials Checklist English
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women English
F-62380 Residential Care Apartment Complex Initial Certification Application English
F-01423 AIDS/HIV Drug Assistance and Insurance Assistance Program Market Place Enrollment Report English
F-05210 Name Change Request Within 1st Year English
F-00044 User Agreement for System Access English
F-29321 COP Cost-Share Worksheet #2 English
F-01930 Minority Health Advisory Group Nomination and Agreement English
F-80477B Canteen Operations Balance Sheet - GAAP Basis English
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment English
F-21042 Medicaid Denial Chart English
F-01668 Consent for Participation in Veterans Outreach and Recovery Program (VORP) English
F-00916 AIDS Drug Assistance Program / Chronic Disease Program / Well Woman Program Provider File Updat Request English
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night English
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request (PDF, 151 KB) English
F-00533 PACE / Partnership Programs - Enrollment English
F-47242 Asbestos Certification Application English
F-11049 Prior Authorization / Drug Attachment (PA/DGA) English
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-specified Community Recovery Services Providers English
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification English
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement English
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) English
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet English
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report English
F-40060 The Emergency Food Assistance Program Commodities Inventory Report English
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis English
F-80921 Invoice Request (PRINT ON BUFF PAPER) English
F-01283 Notification of Non-Covered Benefit Letter Template-Model English
F-21225A Program Participation System (PPS): B-3 Module English
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) English
F-00987B EMS Service Operational Plan Advanced Skills Addendum – Advanced EMT English
F-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request English
F-01118 Child Care Coordination Family Questionnaire English
F-62274A Personal Care Agency Consent for Home Visit Spanish

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Last Revised: July 28, 2017