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 Locationsort descending
F-62652 Home Health Agency Licensure Survey Home Visit Guide
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO
F-01016 ForwardHealth Provider Suggestion
F-16011 Quality Assurance (QA) Sample Checklist
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-00565 County Performance Plan (CPP)
F-00417 AODA Prevention Services Recertification Application - DHS 75.04
F-02250 Quarterly Program Integrity Report
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation
F-62416 Community-Based Residential Facility (CBRF) – Initial Licensure Checklist
F-01942D LTC FS - Change in Condition - Release of Information Authorization
F-62333 Plan Approval Application and Instructions
F-01901 Surgical Site Infection (SSI)
F-47489 EMS Patient Care Worksheet
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program
F-11051 Prior Authorization / Vision Services Attachment (PA/VA)
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding
F-44029 Credit Card Payment
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers
F-62418 Adult Day Care Initial Certification Application
F-01454F IRIS Program Withdrawal Letter - Death
F-62369 Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF)
F-01902 Symptomatic Urinary Tract Infection (SUTI)
F-01593A Civil Money Penality (CMP) Funded Project Report
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding
F-44063 Lead (Pb) Principal Instructor Application
F-05282 Wisconsin Divorce Certificate Application
F-01338 Children's Long-Term Support Parental Fee Declaration Form - Model
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification
F-01207 IRIS Fiscal Employer Agent Quality Management Plan
F-01604 Telehealth Application – Annual Review of Approval
F-00989B Summary of Development (IFSP)
F-40117 Abortion Information Provision Certification
F-01427 Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting
F-25904 Admission to Caseload - Revocation
F-01225 WISEWOMAN Health Coaching Follow-Up
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection
F-00040 Asbestos Course Accreditation - Renewal
F-00987 EMS Service Operational Plan, Advanced Skills Addendum (Basic)
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure
F-00681A Family Care - Three (3) Managed Care Organization (MCO) Options
F-00533 PACE / Partnership Programs - Enrollment
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement
F-02191 CLTS County Waitlist Transition Plan


Last Revised: May 22, 2018