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.
- Cannot Find a Form?
- Ordering Printed Forms or Wisconsin Administrative Codes or Statutes?
- Looking for a publication?
- Having problems opening a form?
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-02191 | CLTS County Waitlist Transition Plan | None |
| F-10137 | Medicaid Change Report | Other |
| F-00169 | Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification | None |
| F-02363 | Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies | None |
| F-02364 | Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers | None |
| F-02365 | Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports | None |
| F-10150 | Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare | None |
| F-19002 | Request to Reduce QUEST Card Balance | None |
| F-16026 | Prosecution Diversion Agreement | None |
| F-10150A | Your Rights and Responsibilities for Health Care | None |
| F-00596 | PPS Mental Health Module | None |
| F-00596a | PPS Mental Health Deskcard | None |
| F-00588 | PPS Alcohol and Other Drug Abuse Module | None |
| F-01205P | IRIS Participant Education: Background Check Process | None |
| F-62696 | Student Nurse / Graduate Nurse Verification | None |
| F-01205M | IRIS Participant Education: Restrictive Measures | None |
| F-01261 | Fraud Statement - IRIS Program | None |
| F-82064 | Background Information Disclosure (BID) | None |
| F-01205B | IRIS Participant Education: Budget Amendments | None |
| F-01205C | IRIS Participant Education: One-Time Expense Requests | None |
| F-01205J | IRIS Participant Education: Self-Directed Personal Care | None |
| F-01205G | IRIS Participant Education: Notices of Action and Appeals | None |
| F-01020 | Nursing Home Care Determination Request | None |
| F-11237 | Specialized Medical Vehicle Providers Affidavit | None |
| F-02008 | CLTS Waivers Certification Exam | None |
| F-021343G | AFCSP Fiscal Report | None |
| F-62546 | Corporate Guardianship Program Annual Report | None |
| F-82069 | Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities | None |
| F-40085 | WIC Program Notice of Ineligibility | None |
| F-02040 | WIC Program Notice of Categorical Ineligibility | None |
| F-02340 | Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement | None |
| F-80025 | Forms / Publications Order | None |
| F-00851 | AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification | None |
| F-00805 | Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators | None |
| F-00238 | Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents | None |
| F-10161 | Statement of Citizenship and/or Identity | None |
| F-00081 | Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine | None |
| F-02265 | Latent Tuberculosis Infection (LTBI) Confidential Case Report | None |
| F-02349 | Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies | None |
| F-10126 | Appoint, Change, or Remove an Authorized Representative | None |
| F-10129 | Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application | None |
| F-10114 | Medicaid Disability Redetermination Report | None |
| F-62447 | Misconduct Incident Report | None |
| F-02341 | County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site | None |
| F-02341A | Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration | None |
| F-02331 | Caregiver Programs Customer Satisfaction Survey | None |
| F-02250 | Quarterly Program Integrity Report | None |
| F-21276 | DCTS Annual Grant/Contract Application | None |
| F-02231 | Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs) | None |
| F-80112 | Vendor Validation | None |
Pages
Last Revised: May 22, 2018
