Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.
| Assigned Number | Title | Division | Other Location |
|---|---|---|---|
| F-13159 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request | DMS | None |
| F-13153 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure | DMS | None |
| F-13160 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization | DMS | None |
| F-13154 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request | DMS | None |
| F-13155 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request | DMS | None |
| F-13156 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request | DMS | None |
| F-13157 | Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request | DMS | None |
| F-01185 | Wisconsin Adult Cystic Fibrosis Program Application | DMS | None |
| F-01184 | Wisconsin Hemophilia Home Care Program Application | DMS | None |
| F-10150B | Your Rights and Responsibilities for FoodShare | DMS | None |
| F-10126 | Appoint, Change, or Remove an Authorized Representative | DMS | None |
| F-01555A | Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility | DMS | None |
| F-62494 | Health Care Facility Construction Documentation Checklist | DQA | None |
| F-62495 | Compliance Statement | DQA | None |
| F-62652 | Home Health Agency Licensure Survey Home Visit Guide | DQA | None |
| F-02642 | Report a Change in Circumstance to Income Maintenance Agencies | DMS | None |
| F-02706 | Recovery Residence Registry Application | DQA | None |
| F-01569 | IRIS Consultant Agency (ICA) Transfer Checklist | DMS | None |
| F-01555 | Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility | DMS | None |
| F-02341A | Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration | DMS | None |
| F-01316 | Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet | DMS | None |
| F-01297 | Medicaid Institution Determination Worksheet | DMS | None |
| F-16019B | FoodShare Wisconsin Registration Packet | DMS | Other |
| F-10182 | BadgerCare Plus Application Packet | DMS | Other |
| F-10127 | Medicaid Purchase Plan (MAPP) - Work Requirement Exemption | DMS | None |
| F-02577 | Proof of In-Kind Hours | DMS | None |
| F-00332 | Medicaid Purchase Plan Premium Information / Payment | DMS | None |
| F-16015 | Notice of Approval of Benefits/Positive Change in Benefits | DMS | None |
| F-01307 | Medicaid Purchase Plan (MAPP) Eligibility Worksheet | DMS | None |
| F-02388 | MIPPA Grant Agency Application | DPH | None |
| F-40044 | Participant Agreement, Rights & Responsibilities | DPH | Other |
| F-02040 | WIC Program Notice of Categorical Ineligibility | DPH | None |
| F-16026 | Prosecution Diversion Agreement | DMS | None |
| F-40085 | WIC Program Notice of Ineligibility | DPH | None |
| F-16028 | Notice of FoodShare Overissuance | DMS | None |
| F-44763 | Emergency Care Do Not Resuscitate Order (DNR) | DPH | None |
| F-40096 | eWIC Program Repayment Agreement | DPH | None |
| F-40028 | Participant Determination Letter | DPH | Other |
| F-16001 | Notice of Denial of Benefits/Negative Change in Benefits | DMS | None |
| F-16004 | Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits | DMS | None |
| F-40036 | Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor | DPH | None |
| F-10150 | Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare | DMS | None |
| F-02491 | FoodShare Buy and Make Food Separately | DMS | None |
| F-16024 | FoodShare Notice of Disqualification | DMS | None |
| F-44161A | WIC Cardholder Rights and Responsibilities | DPH | None |
| F-01891 | New Employment Reporting – FoodShare Employment and Training (FSET) Program | DMS | None |
| F-02431 | Statement About U.S. Military Service | 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-16025 | Disqualification Consent Agreement | DMS | None |
| F-10114 | Medicaid Disability Redetermination Report | DMS | None |
Pages
Last Revised: March 23, 2021
