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 Language
F-82002 Denial of Government Access To Health Care Records (PDF, 13 KB) English
F-02122 Opioid Crisis State Targeted Response Program Funding Request English
F-02022 Claims Audit Report for Managed Long-Term Care MCOs English
F-00017 Blood Lead Lab Reporting English
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing English
F-00596a PPS Mental Health Deskcard English
F-11067 Record of Actual Daily Oxygen Use English
F-00471 CSAS Transitional Residential Treatment Service Recertification Application - DHS 75.14 English
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey English
F-01934 EMS First Responder Training Record - First Responder Refresher Requirements (PDF, 647 KB) English
F-01733 FoodShare Outreach Project Proposal English
F-01631 ADRC Call Summary Sheet English
F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices English
F-00603 PPS (Program Participation System) Core Module English
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request English
F-00472 CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 English
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) English
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB) English
F-01935 EMS First Responder Training Record - NCCP First Responder Refresher Requirements (PDF, 201 KB) English
F-01735 CLIA Laboratory Test Methodology Report English
F-01623 OARS - Residential Placement Reviews English
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) English
F-00989J Transition Plan - Turning 3 Years Old (IFSP) English
F-44018 Request for Repairs (PDF, 27 KB) English
F-10093 Medicaid and BadgerCare Plus Overpayment Notice English
F-40098 Worksite Wellness Kit Survey and Request English
F-01348C Itemized Method-B Non-salary Cost Worksheet CM-III (b) (Model) (PDF, 68 KB) English
F-25393 Petition for Conditional Release English
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs English
F-01165 Newborn Report English
F-01411 Education-Medication Summary - Part B English
F-01729 Nonprobate Asset/Property Disclosure English
F-80882 Contract Summary (CARS) English
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet English
F-62654 Home Health Agency Licensure Survey Exit Conference Guide English
F-00169 Opting Out of Local Educational Agency (LEA) Notification English
F-20445 Individual Service Plan - Medicaid Waivers English
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation English
F-01011 Medicaid - Physician Certification / Recertification of Terminal Illness English
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request (PDF, 163 KB) English
F-00784 Personal Care Agency Client Rights English
F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan English
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 English
F-00401 Expedited Emergency Supply Request English
F-02053 ADRC Referral to Income Maintenance English
F-00311 Nursing Home MDS 3.0 Section Q Referral English
F-02011 Fluoride Mouthrinse Program Annual Report English
F-01894 Vendor Overpayment Findings Letter English
F-60309 Self-Supervision Evaluation and Waiver Request English
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants English


Last Revised: July 28, 2017