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 Division Other Location
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-82018C Work Time Absence Record DES
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-11240 Case Management Provider Information OIG
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation DPH
F-22565 Authorization for Recoupment Caretaker Supplement DMS
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS
F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease DMS
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-44819 Farmers Market Nutrition Program (FMNP) - Application for Farm Stand DPH
F-47470 Change of EMS Medical Director DPH
F-11022 Rural Health Clinic Statistical Data DMS
F-47479 Trauma Care Facility Classification Application DPH
F-02538 Children’s Long-Term Support Waiver Program—Outlier Rate Request DMS
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) DMS
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DMS
F-01359 Historical Earnings Verification Request DMS
F-01161 Abortion Certification Statements DMS
F-10146 Employer Verification of Earnings DMS
F-01302 Weekly Driver's Vehicle Inspection Report DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-01165 Newborn Report DMS
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care DMS
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services DCTS
F-00114 EMS Service Director License Proxy for Individuals DPH
F-00568 EMS Board Sub-Committee Appointment Application DPH
F-01068L General Pediatric Clinic - Teenager Visit DMS
F-01068F General Pediatric Clinic - 12 Month Visit DMS
F-01068M Confidential Health Survey DMS
F-01068G General Pediatric Clinic - 15 Month Visit DMS
F-01068A General Pediatric Clinic - 3 to 4 Week Visit DMS
F-01068H General Pediatric Clinic - 18 Month Visit DMS
F-01068B General Pediatric Clinic - 6 to 8 Week Visit DMS
F-01068i General Pediatric Clinic - 24 Month Visit DMS
F-01068C General Pediatric Clinic - 4 Month Visit DMS
F-01068J General Pediatric Clinic - Preschool Visit DMS
F-01068D General Pediatric Clinic - 6 Month Visit DMS
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies DMS
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers DMS
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports DMS
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-01062 HealthCheck Adolescent Review DMS

Pages

Last Revised: March 26, 2019