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 Division Other Location
F-02574 Wisconsin Assistive Technology Advisory Council Application DPH
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH
F-01421 WISEWOMAN Monthly Reporting for Direct Services DPH
F-01781 Immunization Program Functional Exercise 2018-2020 (BP1 Supplemental) DPH
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-02562 Disability Benefit Specialist Program Client Services Agreement DPH
F-02583 Options Counseling Record Review Tool DPH
F-80857 Special CARS Run request DES
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request DPH
F-11133 Personal Care Screening Tool (PCST) DMS
F-16033 FoodShare Worksheet DMS
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook DCTS
F-01218 WISEWOMAN Client Consent DPH
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-00888 ADRC Action Plan DPH
F-01219 WISEWOMAN Health History Assessment DPH
F-00688 Referral to Wisconsin Birth to 3 Program DMS
F-62593 Nurse Aide Training Program Annual Report DQA
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-62504 Behavioral Health Certification Section: Initial Certification Application DQA
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 DQA
F-62592 Feeding Assistant Training Program Annual Review Report DQA
F-25180 Order of Discharge Upon Expiration of Commitment DCTS
F-29314 COP Declaration of Income and Assets, and State Residency DPH
F-02112A Definitions of Evidence-Based Practices (EBPs) for the CSP and CCS Program Surveys DCTS
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-44764 Do Not Resuscitate Bracelet - Electronic Format DPH
F-02541 Wisconsin Birth Defects Condition Nomination DPH
F-16028 Notice of FoodShare Overissuance DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-29315 Declaration of Income and Assets, and State Residency Instructions DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-00330 Request for Replacement FoodShare Benefits DMS
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments DPH
F-40085 WIC Program Notice of Ineligibility DPH
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement DPH
F-40310 Adult Oral Health Screening DPH
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site DMS
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy DPH
F-62610 Nurse Aide Training Program Primary Instructor Application DQA


Last Revised: March 26, 2019