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-20935 Status Report to Court for Plan Compliance
F-00309 Medicaid Provider Report
F-20933 Court Order for Assessment
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet
F-20891 Intoxicated Driver Program Supplemental Funding Request
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools
F-21343E Alzheimer's Family and Caregiver Support Program (AFCSP) General Information
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-13033 Probate Claims Notice
F-02230 County Agency Children's Community Option Program (CCOP) Annual Plan Update
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument
F-05020 Paternity Order Due to Divorce - Judgment
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results
F-00164 Civil Rights Compliance Plan
F-47472 Emergency Medical Technician (EMT) License / First Responder Certification Renewal Application
F-01286 Template for Transition - Final Plan
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06
F-01159 Commercial Other Coverage Discrepancy Report
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook
F-00004A Health and Employment Counseling - I Think I Need More Time
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-00004B Health and Employment Counseling - I Have Reached Employment
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement
F-01781 Immunization Program Functional Exercise 2018-2019 (BP1 Supplemental)
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-00004 Health and Employment Counseling Application
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-02108 Adult Family Home
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement
F-04020L Student Immunization Record, Long
F-01601A CST Summary Line Item Budget
F-02369 Certification of Need for Laboratory Services
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification
F-10137 Medicaid Change Report
F-00657 Nurse Aide Training Program: Military Training Verification
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist
F-02191 CLTS County Waitlist Transition Plan
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-19002 Request to Reduce QUEST Card Balance
F-16026 Prosecution Diversion Agreement
F-10150A Your Rights and Responsibilities for Health Care
F-00596 PPS Mental Health Module
F-00596a PPS Mental Health Deskcard
F-00588 PPS Alcohol and Other Drug Abuse Module
F-62696 Student Nurse / Graduate Nurse Verification
F-82064 Background Information Disclosure (BID)


Last Revised: March 26, 2019