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 Numbersort descending Title Other Location Language
F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 English
F-00517 CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 English
F-00518 CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 English
F-00519 CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 English
F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 English
F-00521 CSAS Prevention Service Initial Certification Application - DHS 75.04 English
F-00523 Community Substance Abuse Service General Requirements Initial Certification Application - DHS 75.03 English
F-00533 PACE / Partnership Programs - Enrollment English
F-00534 PACE / Partnership Member Requested Disenrollment English
F-00537 CSAS Intervention Services Initial Certification Application - DHS 75.16 English
F-00538 CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 English
F-00539 Children's Long Term Support Service Coordination Rate Worksheet English
F-00539A General Support and Service Coordination Rate Certification Worksheet English
F-00543A Self-Assessment / On-Site File Review Checklist English
F-00544 CSAS Outpatient Treatment Service Initial Certification Application - DHS 75.13 English
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 English
F-00546 CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 English
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 English
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 English
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 English
F-00553 Professional & Occupational License Application & Affidavit English
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger English
F-00565 County Performance Plan (CPP) English
F-00565A County Performance Plan (CPP) Outcomes English
F-00567 Emergency Medical Services Complaint English
F-00568 EMS Board Sub-Committee Appointment Application English
F-00569 Request for Waiver of Administrative Rule for Licensure English
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 English
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) English
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application English
F-00576A Tribal Aging and Disability Resource Specialist (TADRC) Annual Budget English
F-00577 Report Fraud English
F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System English
F-00588 PPS Alcohol and Other Drug Abuse Module English
F-00588a PPS AODA Deskcard (PDF, 181 KB) English
F-00596 PPS Mental Health Module English
F-00596a PPS Mental Health Deskcard English
F-00603 PPS (Program Participation System) Core Module English
F-00603a PPS Core Deskcard (PDF, 20 KB) English
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application English
F-00615 Change Project Report English
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable English
F-00628 Consortium Response to the State IM Second Party Review Finding English
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information English
F-00633 Notice and Consent for Screening English
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records English
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program English
F-00634B Records Access Log, Birth to 3 Program English
F-00639 Agency Data Security Staff User Agreement English
F-00642 Community Aids Reporting System (CARS) Expenditure Report English

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Last Revised: July 28, 2017