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-02483 PACE Program Enrollment DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00533 Partnership Programs - Enrollment DPH
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-02558 Family Care Member County Notification DMS
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-01586 Medical Stockpile Access Request DPH
F-10162 Verification of Veterans Benefits DMS
F-02436 Testing Questionnaire (AIDS/HIV) DPH
F-02436A PrEP Questionnaire DPH
F-01204E Letter – IRIS Program Notice of Action – Functional Eligibility DMS
F-01204A Letter – IRIS Program Notice of Action – Denial DMS
F-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-01204C Letter – IRIS Program Notice of Action – Reduction DMS
F-01204D Letter – IRIS Program Notice of Action – Termination DMS
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change DMS
F-02616 Supervised Release (SR) Client Vehicle Purchase Request DCTS
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-02622 Vendor/Participant Complaint: Wisconsin WIC and Senior Farmers' Market Nutrition Program (FMNP) DPH
F-02445 REDCap Setup Request DPH
F-02530 Application for Wisconsin's Test of English Proficiency (TEP) and Board for Examination of Interpreters (BEI) DPH
F-10182 BadgerCare Plus Application Packet DMS
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions DMS
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application DMS
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral OIG
F-12022 Managed Care Program Provider Appeal DMS
F-00639 Agency Data Security Staff User Agreement DMS
F-02314E Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation for Annual Employee Screening DPH
F-02620 Supervised Release (SR) Client Contact Request DCTS
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit DMS
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement DMS
F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement DMS
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-02596 Youth Crisis Stabilization Facilities (YCSF): Extension of Stay Authorization DCTS
F-02112 2017 Community Support Program (CSP) Survey Worksheet DCTS
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License DPH
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting DMS
F-00004B Health and Employment Counseling - I Have Reached Employment DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-02614 Fraud Prevention and Investigation Program (FPIP) Fraud Year Contact Information OIG
F-02565 Community Recovery Services (CRS) Staff Background Check Confirmation DCTS
F-02050 Coordinated Services Teams (CST) Final Expenditure Report DCTS
F-02110C RCAC: New Provider Certification / Registration Application DQA
F-02110D RCAC: New Provider Certification / Registration Application Checklist DQA
F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671 DQA

Pages

Last Revised: March 26, 2019