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-02191 CLTS County Waitlist Transition Plan
F-10137 Medicaid Change Report
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies
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
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
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-19002 Request to Reduce QUEST Card Balance
F-16026 Prosecution Diversion Agreement
F-10150A Your Rights and Responsibilities for Health Care
F-00596 PPS Mental Health Module
F-00596a PPS Mental Health Deskcard
F-00588 PPS Alcohol and Other Drug Abuse Module
F-01205P IRIS Participant Education: Background Check Process
F-62696 Student Nurse / Graduate Nurse Verification
F-01205M IRIS Participant Education: Restrictive Measures
F-01261 Fraud Statement - IRIS Program
F-82064 Background Information Disclosure (BID)
F-01205B IRIS Participant Education: Budget Amendments
F-01205C IRIS Participant Education: One-Time Expense Requests
F-01205J IRIS Participant Education: Self-Directed Personal Care
F-01205G IRIS Participant Education: Notices of Action and Appeals
F-01020 Nursing Home Care Determination Request
F-11237 Specialized Medical Vehicle Providers Affidavit
F-02008 CLTS Waivers Certification Exam
F-021343G AFCSP Fiscal Report
F-62546 Corporate Guardianship Program Annual Report
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities
F-40085 WIC Program Notice of Ineligibility
F-02040 WIC Program Notice of Categorical Ineligibility
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement
F-80025 Forms / Publications Order
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents
F-10161 Statement of Citizenship and/or Identity
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies
F-10126 Appoint, Change, or Remove an Authorized Representative
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application
F-10114 Medicaid Disability Redetermination Report
F-62447 Misconduct Incident Report
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site
F-02341A Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration
F-02331 Caregiver Programs Customer Satisfaction Survey
F-02250 Quarterly Program Integrity Report
F-21276 DCTS Annual Grant/Contract Application
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-80112 Vendor Validation

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Last Revised: May 22, 2018