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-47242 Asbestos Certification Application
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information
F-01601B ISP Line Item Detail Budget
F-05004 Birth Amendment - Affidavit
F-44013 Lead-Based Paint (LBP) Investigation Summary Report
F-00202 Individual Service Plan - Community Recovery Services (CRS)
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-01201C IRIS Participant Employer / Participant-Hired Worker Agreement
F-29315 Instructions: Declaration of Income and Assets and State Residency
F-02331 Caregiver Programs Customer Satisfaction Survey
F-00004 Health and Employment Counseling Application
F-82018C Work Time Absence Record
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program
F-02051 Wisconsin Donor Registry Enrollment
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions
F-62589 Telehealth Application – Initial Approval
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program
F-01932 Wisconsin EMS EMT Training Record - EMT Refresher Requirements
F-11019 Prior Authorization / Physician Otological Report (PA/POR)
F-47478 First Responder / Emergency Medical Technician Application Electronic Addition to a Roster
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36
F-01651 Employee Information
F-05035 Report Change Name, Sex Birth Certificate Surgical Procedure
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services
F-00727 Typical Hearing Developmental Milestones
F-01208 IRIS Consultant Agency Quality Management Plan
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training
F-00681DL IRIS (Include, Respect, I Self-Direct) Two Consultant Agency Options (Large Print)
F-00040 Asbestos Course Accreditation - Renewal
F-01224 WISEWOMAN Healthy Behavior Initial Support
F-21078 Children's Long-Term Support (CLTS) Waivers Recertification Checklist
F-02124 2016 Comprehensive Community Services (CCS) Program Survey Worksheet
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure
F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits
F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA)
F-62024 Report of Hours Worked - Nurse Aide / Day
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03
F-10076 SeniorCare Application
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels
F-00309 Medicaid Provider Report
F-00989C Summary of Development Child’s Positive Social Emotional Skills (IFSP)
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement
F-02385 Vaccine Accountability -Vaccine Preventable Disease: Tetanus
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC
F-01359 Historical Earnings Verification Request
F-21336 Consent for Exchange of Information with Local Educational Agency

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Last Revised: May 22, 2018