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-47181 First Responder Certification Card
F-00539 Children's Long Term Support Service Coordination Rate Worksheet
F-01598 Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents
F-10191 Medicaid Annuity Beneficiary Designation
F-44003 Lead-Safe Renovator Application
F-00315A Written Prior Notice - No Evaluation Recommended
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-05022T Report of Adoption - Tribal
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization
F-82003 Denial of Researcher Access To Health Care Records
F-01205D IRIS Participant Education: Program Integrity - Fraud Prevention
F-20818 Certification for SSI-E Exceptional Expense Supplement
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report
F-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request
F-01002 HealthCheck Individual Health History
F-01901 Surgical Site Infection (SSI)
F-13074 Pharmacy Special Handling Request
F-47464 Emergency Medical Technician - Basic IV Training Permit Application
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application
F-01649 Coverdell Stroke Champion Partner Agreement
F-11027 Rural Health Clinic Quarterly Cost Report
F-44126 Antituberculosis Therapy Program Medication Refill Request
F-00366 Wisconsin Adult Long-Term Care Functional Screen
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bedhold Days
F-05098 Court Order to Correct Facts, Misrepresented Information
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing
F-00681L Partnership - Three (3) Managed Care Organization (MCO) Options (Large Print)
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-01219 WISEWOMAN Health History Assessment
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home / Institution
F-62528 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Checklist
F-62643 Drug Repository Program Notice of Participation or Withdrawal
F-01062 HealthCheck Adolescent Review
F-00681CCC Family Care - Managed Care Organization (MCO) Four (4) Options
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist
F-00639 Agency Data Security Staff User Agreement
F-01619 OARS Welcome Letter
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21
F-44755 WIC Farmers' Market Nutrition Program
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification
F-22491A Consumer Survey – OBVI
F-10098 Medicaid Member Asset Allocation Notice
F-40071 Children's Physical Activity Chart
F-01999A 2020 Retired Senior Volunteer Program: State Match Funding Application
F-40072 8 Week Activity Log
F-02369 Certification of Need for Laboratory Services

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Last Revised: May 22, 2018