Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Location
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-02925 Request for HIV Care Grievance Resolution DPH
F-47470 Change of EMS Medical Director DPH
F-80190 Travel Reimbursement Request Non-State Employee DES
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application DMS
F-00388 County Birth to 3 Fiscal Reconciliation Report DMS
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-02941 Community Engagement Assessment Tool (Simplified) DPH
F-16019A FoodShare Wisconsin Registration DMS
F-82064 Background Information Disclosure (BID) DQA
F-16019B FoodShare Wisconsin Registration Packet DMS
F-021343G AFCSP Fiscal Report DPH
F-02919 Vendor Performance Report for Division of Medicaid Services (DMS) DMS
F-01293D Participant Fiscal Employer Agent (FEA) Transfer Checklist DMS
F-01454G IRIS Program Withdrawal Letter – Cancelled DMS
F-01454C IRIS Program Withdrawal Letter – No Contact DMS
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-02634 Adult Day Care Center (ADCC) Initial Survey Checklist DQA
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS
F-01319C IRIS Program – Denial of Enrollment Letter DMS
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility DMS
F-01454E IRIS Program Withdrawal Letter – Voluntary DMS
F-01454F IRIS Program Withdrawal Letter – Death DMS
F-01556D IRIS Program Letter – Disenrollment DMS
F-01442C IRIS Program Disenrollment Letter – No Contact DMS
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-01454 IRIS Program Withdrawal Letter – No Progress DMS
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting DMS
F-01442J IRIS Program Disenrollment Letter - Mismanagement DMS
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility DMS
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page DMS
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS
F-01442G IRIS Program Disenrollment Letter – Non-Spending DMS
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-02749 CLTS Exceptional Expense Notification DMS
F-02106A Adult Day Care Center — Certification Application DQA
F-02106B Adult Day Care Center — Certification Application Checklist DQA
F-02927 Nurse Aide Training Prohibition Waiver Request DQA
F-02106 Adult Day Care Center – Applicant Compliance Statement DQA
F-02759 Comprehensive Community Services Cost Settlement Advance Request DMS
F-00334 Money Follows the Person (MFP) - Participant Reporting DMS
F-20582 Medicaid – Katie Beckett Program Application DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-02764 Participant Fiscal Employer Agent (FEA) – Transfer Request DPH
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-02891 Durable Medical Equipment Home Accessibility Evaluation DMS
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura DMS


Last Revised: June 16, 2022