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-01679 Communicable Disease / Tuberculosis Screening Questionnaire
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use)
F-10144 Life Insurance Inquiry
F-44011 Application for Registration of Lead-Free or Lead-Safe Property
F-01302 Weekly Driver's Vehicle Inspection Report
F-00171 Lead Company Application
F-00714 Business Associate Agreement - County or Tribal Contract
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s)
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program
F-40085 WIC Program Notice of Ineligibility
F-22638 Notification of Waiver Program Termination
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS)
F-01205C IRIS Participant Education: One-Time Expense Requests
F-01406 Asthma Care (Release of Information )
F-21059 Variance Request for Institutional Respite
F-01068J General Pediatric Clinic - Preschool Visit
F-16038 Administrative Disqualification Hearing Notice
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTSS
F-00646 Emergency Medical Service Training Center - Training Permit Eligibility Certification
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement
F-11136 Personal Care Addendum
F-80130 Financial Information 
F-02050 Coordinated Services Teams (CST) Final Expenditure Report
F-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request
F-13149 HIPAA Privacy Accounting Request
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review
F-62151 Nursing Home Residents' Rights Complaint Report
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-11018 Prior Authorization Request Form (PA/RF)
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB)
F-00262A Personal Care Agency Application Regulatory Guidance Checklist
F-44212 School Report to the District Attorney
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion
F-44763 Emergency Care - Do Not Resuscitate Order (DNR)
F-01275A IRIS Provider Executive Staff Disclosure
F-00016 Wall Closure Inspection Checklist
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting
F-01261 Fraud Statement - IRIS Program
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI)
F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit
F-01208A IRIS Consultant Agency Quality Management Plan Tracking
F-02257 Temperature Excursion Incident Report - WIsconsin Vaccines for Children Program (VFC)
F-80983 Civil Rights Complaint
F-20891 Intoxicated Driver Program Supplemental Funding Request
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications
F-62680 Home Health Agency Clinical Record Review
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process


Last Revised: May 22, 2018