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-16019B FoodShare Wisconsin Registration Packet
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis
F-62151 Nursing Home Residents' Rights Complaint Report
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35
F-01205P IRIS Participant Education: Background Check Process
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents
F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-00989P Individualized Family Service Plan Team Signature (IFSP)
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips
F-01389B Mental Health Statistical Improvement Program (MHSIP) Family Satisfaction Survey
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-44160A WIC Plastic Cover for WIC ID Folder
F-00036 Power of Attorney for Finance and Property
F-80188 Check Distribution / Attachments
F-01182 Declaration of Supervision for Nonbilling Providers
F-16039 Waiver of Administrative Disqualification Hearing
F-01942D LTC FS - Change in Condition - Release of Information Authorization
F-62288 Care Level Determination Worksheet
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance
F-01751 Request for IMD Rebalancing Initiative Funding – Summary
F-11289 HealthCheck County Outreach Case Management Plan for County
F-45020 Cumulative Occupational Exposure History
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
F-01205J IRIS Participant Education: Self-Directed Personal Care
F-10175 Statement of Identity for Persons in Institutional Care Facilities
F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-04020 Student Immunization Record - This form is intended for schools
F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-00054 Request for Waiver of Education / Experience Requirements (ADRC)
F-80857 Special CARS Run request
F-01201B IRIS Supportive Home Care / Self-Directed Personal Care / Respite Care Training Verification
F-20445A Individual Service Plan - Individual Outcomes
F-02046 IRIS Financial Projections Template
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center
F-01781 Immunization Program Functional Exercise 2017-2018 (BP6)
F-12089 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request
F-47198 Noise Exposure Sampling Sheet
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34
F-01596 Incident Report for CIP 1A/1B, CIP II, and COP-W Medicaid Waiver Programs
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services
F-44005 Visual Inspection of Registered Lead-Safe Property
F-00334 Money Follows the Person (MFP) - Participant Reporting


Last Revised: May 22, 2018