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-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies
F-10126 Appoint, Change, or Remove an Authorized Representative
F-01204A Letter - IRIS Program Notice of Action - Denial
F-01204B Letter - IRIS Program Notice of Action - Limit
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application
F-10114 Medicaid Disability Redetermination Report
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site
F-02341A Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration
F-62447 Misconduct Incident Report
F-02331 Caregiver Programs Customer Satisfaction Survey
F-21276 DCTS Annual Grant/Contract Application
F-02250 Quarterly Program Integrity Report
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events
F-80112 Vendor Validation
F-00107 Self-Employment Income Report
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information
F-83263 Rehabilitation Review Application and Instructions
F-02329 VFC Change of Information
F-25393A Petition for Supervised Release
F-82002 Denial of Government Access To Health Care Records
F-01309 IRIS Program Orientation and Enrollment Checklist
F-82021 Researcher's Request for Confidential Records or Human Subjects Research
F-82003 Denial of Researcher Access To Health Care Records
F-82006 Employment Application and Resume
F-82009AA Confidential Information Release Authorization - Katie Beckett Program
F-82009 Confidential Information Release Authorization - Generic 
F-80976 Employment and Education History Summary
F-80911 Limited Term Employment (LTE) or Project Employment Application
F-80921 Invoice Request (PRINT ON BUFF PAPER)
F-80479 Audit Confirmation Request
F-80751 Non-County Resident Proceedings Cost Certification
F-80761 Contingent Account Activity Report
F-80783A Family Financial Questionnaire - County Use
F-16038 Administrative Disqualification Hearing Notice
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-00615A Change Project Summary and Instructions
F-62611 Family Adult Day Care Certification Standards Checklist
F-62657 Home Health Agency Contract Review Worksheet
F-62595 Long-term Care Facility Feeding Assistant Roster
F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits
F-62692 Feeding Assistant Training Program Primary Instructor Application
F-80130 Financial Information 
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
F-62601 Rights of Home Health Agency Patients
F-62671 Adult Family Home (AFH) Initial Licensure Checklist
F-80013 Petty Cash Fund Annual Report
F-62651A Personal Care Agency Calendar Worksheet - Prescribed Visits
F-62643 Drug Repository Program Notice of Participation or Withdrawal

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Last Revised: May 22, 2018