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 Division Other Location
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) DMS
F-01161 Abortion Certification Statements DMS
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DMS
F-10146 Employer Verification of Earnings DMS
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-01302 Weekly Driver's Vehicle Inspection Report DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care DMS
F-00380 Outpatient Mental Health Clinic Certification Withdrawal DQA
F-02522 Supervised Release Individual Client Summary DCTS
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services DCTS
F-00114 EMS Service Director License Proxy for Individuals DPH
F-00568 EMS Board Sub-Committee Appointment Application DPH
F-01068F General Pediatric Clinic - 12 Month Visit DMS
F-01068M Confidential Health Survey DMS
F-01068G General Pediatric Clinic - 15 Month Visit DMS
F-01068A General Pediatric Clinic - 3 to 4 Week Visit DMS
F-01068H General Pediatric Clinic - 18 Month Visit DMS
F-01068B General Pediatric Clinic - 6 to 8 Week Visit DMS
F-01068i General Pediatric Clinic - 24 Month Visit DMS
F-01068C General Pediatric Clinic - 4 Month Visit DMS
F-01068J General Pediatric Clinic - Preschool Visit DMS
F-01068D General Pediatric Clinic - 6 Month Visit DMS
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-01068L General Pediatric Clinic - Teenager Visit DMS
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies DMS
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers DMS
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports DMS
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-02535 Nursing Home: Notice of Change for Administrator of Director of Nursing DQA
F-01062 HealthCheck Adolescent Review DMS
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement DMS
F-01063 HealthCheck Family History DMS
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness DMS
F-82009Y Confidential Information Release Authorization - Testing Records DCTS
F-80761 Annual Contingent Account Activity Report DES
F-62657 Home Health Agency Contract Review Worksheet DQA
F-80962 New Capital Asset Record DES
F-80476 Asset Transfer DES
F-62692 Feeding Assistant Training Program Primary Instructor Application DQA
F-80900 Receivables Annual Report DES
F-80188 Check Distribution / Attachments DES
F-82006 Employment Application and Resume DES
F-80762 Store Inventory Reconciliation Worksheet DES

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Last Revised: March 26, 2019