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-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s)
F-11285 HealthCheck Screener Affirmation
F-01442C IRIS Program Disenrollment Letter – No Contact
F-25614 Conditional Release Rules and Conditions
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding
F-80976 Employment and Education History Summary
F-00943 Exhibit II - Tribal Work Plan
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals
F-44215 Child Care Center Report to the District Attorney
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13
F-01900 Laboratory-Identified C.Difficile Infection Events In Hospitals
F-01201A IRIS Participant - Hired Worker Relationship Identification
F-47463C Intermediate Technician Operational Plan Components
F-00315D Written Prior Notice - Additional Assessment Recommended
F-01542 Notification of Required Drug Testing
F-44089 Wisconsin WIC Checks Accepted Here - Stickers
F-00085 Power of Attorney for Health Care
F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice
F-01468 IRIS Program Start Date Letter – New Participant
F-40019 Affirmation of Identity, Residency, and/or Income
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3)
F-01406 Asthma Care (Release of Information )
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home / Institution
F-60947 Adult Day Care Initial Certification Checklist
F-05029 Request To Withdraw Voluntary Paternity Acknowledgement
F-62610 Nurse Aide Training Program Primary Instructor Application
F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System
F-01938 Wisconsin EMS Paramedic Training Record - NCCP Paramedic Refresher Requirements
F-01206B IRIS One-Time Expense Request - Ramp
F-60309 Self-Supervision Evaluation and Waiver Request
F-00367B Age-Specific ADL / IADL Answer Choices for Cildren's Long-Term Support Programs Age: 6 - 12 Months
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report
F-44702 Vaccine Administration Record
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request
F-13148 HIPAA Privacy Access Request
F-01545 IRIS Fiscal Employer Agent (FEA) Biography
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA)
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement
F-05282 Wisconsin Divorce Certificate Application
F-62674A Model Balance Sheet

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Last Revised: May 22, 2018