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.
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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 | Division | Other Location |
|---|---|---|---|
| F-02574 | Wisconsin Assistive Technology Advisory Council Application | DPH | None |
| F-11040 | Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) | DMS | None |
| F-00212 | Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment | DMS | None |
| F-01629 | Prior Authorization / Behavioral Treatment Attachment (PA/BTA) | DMS | None |
| F-02570 | Emergency Medical Services (EMS) E-Licensing Service Demographic Information | DPH | None |
| F-01421 | WISEWOMAN Monthly Reporting for Direct Services | DPH | None |
| F-01781 | Immunization Program Functional Exercise 2018-2020 (BP1 Supplemental) | DPH | None |
| F-00163 | Prior Authorization / Drug Attachment for Anti-Obesity Drugs | DMS | None |
| F-02562 | Disability Benefit Specialist Program Client Services Agreement | DPH | None |
| F-02583 | Options Counseling Record Review Tool | DPH | None |
| F-80857 | Special CARS Run request | DES | None |
| F-16030 | FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator | DMS | None |
| F-20891 | Intoxicated Driver Program Supplemental Funding Request | DCTS | None |
| F-16004 | Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits | DMS | None |
| F-10126 | Appoint, Change, or Remove an Authorized Representative | DMS | None |
| F-20483 | Wisconsin Incident Tracking System (WITS) Web Access Request | DPH | None |
| F-11133 | Personal Care Screening Tool (PCST) | DMS | None |
| F-16033 | FoodShare Worksheet | DMS | None |
| F-01391 | Recovery Oriented System Indicator (ROSI) Adult Data Workbook | DCTS | None |
| F-01218 | WISEWOMAN Client Consent | DPH | None |
| F-01228 | WISEWOMAN Follow-up Assessment: LSP/HC Complete | DPH | None |
| F-00888 | ADRC Action Plan | DPH | Other |
| F-01219 | WISEWOMAN Health History Assessment | DPH | None |
| F-00688 | Referral to Wisconsin Birth to 3 Program | DMS | None |
| F-62593 | Nurse Aide Training Program Annual Report | DQA | None |
| F-01205C | IRIS Participant Education: One-Time Expense Requests | DMS | None |
| F-62504 | Behavioral Health Certification Section: Initial Certification Application | DQA | None |
| F-00467 | Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 | DQA | None |
| F-62592 | Feeding Assistant Training Program Annual Review Report | DQA | None |
| F-25180 | Order of Discharge Upon Expiration of Commitment | DCTS | None |
| F-29314 | COP Declaration of Income and Assets, and State Residency | DPH | None |
| F-02112A | Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys | DCTS | None |
| F-11083 | Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) | DMS | None |
| F-44764 | Do Not Resuscitate Bracelet - Electronic Format | DPH | None |
| F-02541 | Wisconsin Birth Defects Condition Nomination | DPH | None |
| F-16028 | Notice of FoodShare Overissuance | DMS | None |
| F-16038 | Administrative Disqualification Hearing Notice | DMS | None |
| F-29315 | Declaration of Income and Assets, and State Residency Instructions | DMS | None |
| F-02340 | Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement | DMS | None |
| F-00330 | Request for Replacement FoodShare Benefits | DMS | None |
| F-40076 | Women, Infants, and Children (WIC) Nutrition Program Employer Statement | DPH | None |
| F-47300 | Ambulance Run Report (page 3) Skills / Extended Comments | DPH | None |
| F-40085 | WIC Program Notice of Ineligibility | DPH | None |
| F-40019 | Affirmation of Identity, Residency, and/or Income | DPH | None |
| F-02013 | TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets | DPH | None |
| F-40309A | Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement | DPH | None |
| F-40310 | Adult Oral Health Screening | DPH | None |
| F-02341 | County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site | DMS | None |
| F-40309 | Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy | DPH | None |
| F-62610 | Nurse Aide Training Program Primary Instructor Application | DQA | None |
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Last Revised: March 26, 2019
