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
F-20933 Court Order for Assessment
F-20934 Court Ordered Assessment and Plan Report
F-20934A Plan Recommendation
F-20935 Status Report to Court for Plan Compliance
F-00309 Medicaid Provider Report
F-00588a PPS AODA Deskcard
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet
F-20891 Intoxicated Driver Program Supplemental Funding Request
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools
F-21343A Alzheimer's Family and Caregiver Support Program (AFCSP) Financial Eligibility Screen - Worksheets 1 and 2
F-02390 Fall Medicare Training Participant Survey
F-21343E Alzheimer's Family and Caregiver Support Program (AFCSP) General Information
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-13033 Probate Claims Notice
F-02230 County Agency Children's Community Option Program (CCOP) Annual Plan Update
F-02282 Resident Relocation Roster
F-02367 Non-Addictive, Non-Narcotic, Injectable Medication (NNAI) Medication Assisted Treatment (MAT) Service within the Jail Setting NNAI MAT Re-Entry Grant Application
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist
F-44764 DNR Bracelet Inserts (22 inserts/sheet)
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument
F-05020 Paternity Order Due to Divorce - Judgment
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results
F-01159 Commercial Other Coverage Discrepancy Report
F-00164 Civil Rights Compliance Plan
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06
F-01286 Template for Transition - Final Plan
F-47472 Emergency Medical Technician (EMT) License / First Responder Certification Renewal Application
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook
F-00004B Health and Employment Counseling - I Have Reached Employment
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement
F-00004A Health and Employment Counseling - I Think I Need More Time
F-01781 Immunization Program Functional Exercise 2018-2019 (BP1 Supplemental)
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center
F-00237SO Appeal Request - MCOs, Somali
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-00004 Health and Employment Counseling Application
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint
F-02108 Adult Family Home
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement
F-04020L Student Immunization Record, Long
F-01601A CST Summary Line Item Budget
F-02369 Certification of Need for Laboratory Services
F-00476 CARES Automated Systems Access Request
F-10137 Medicaid Change Report
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification


Last Revised: May 22, 2018