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 Locationsort descending
F-16021 Student Financial Aid Report
F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application
F-11066 Prior Authorization / Oxygen Attachment (PA/OA)
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06
F-00315C Prior Notice and Consent for Evaluation and Assessment
F-02122 Opioid Crisis State Targeted Response Program Funding Request
F-02022 Claims Audit Report for Managed Long-Term Care MCOs
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report
F-01933 WIsconsin EMS EMT Training Record - NCCP EMT Refresher Requirements
F-60367 Community Advisory Committee Documentation
F-01726 Basic Equipment List for Nurse Aide Training Programs
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources
F-44126 Antituberculosis Therapy Program Medication Refill Request
F-10080 SeniorCare Authorization of Representative
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-01346 Behavior Monitoring Record-Model
F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Providers
F-01210A IRIS Budget Amendment Provider Quote Comparison
F-00052 Aging and Disability Resource Center (ADRC) Application
F-01634 WorkPlace Wellness Grant Program Application
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP)
F-01442 IRIS Disenrollment Letter - Death
F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement
F-01229 WISEWOMAN Provider Assurances and Training Checklist
F-21334 Encounter New User Request
F-80479 Audit Confirmation Request
F-01153 Breast Pump Order
F-20448 Request for Medicaid Administrative Funds - Staff Position
F-00987D EMS Service Operational Plan Advanced Skills Addendum (Paramedic)
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request
F-00703 Patient Side Training Report
F-00539 Children's Long Term Support Service Coordination Rate Worksheet
F-00681BL Partnership - Two (2) Managed Care Organization (MCO) Options (Large Print)
F-02210 Request for Dane County Support Broker to Attend Enrollment Counseling Session
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request
F-62610 Nurse Aide Training Program Primary Instructor Application
F-01954 Wisconsin EMS Training Record NCCP AEMT Refresher Requirements
F-62274A Personal Care Agency Consent for Home Visit
F-11304 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-47463D Intermediate Operational Plan Components
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA)
F-45007 Certificate of Disposition of Materials
F-10144 Life Insurance Inquiry
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request
F-00021 HealthCheck Referral
F-01681 Comprehensive Community Services (CCS) Technical Assistance Survey
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup

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Last Revised: May 22, 2018