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 Language
F-00685 Statement of Tribal Affiliation English
F-00476 CARES Automated Systems Access Request English
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 English
F-00603a PPS Core Deskcard English
F-00401 Expedited Emergency Supply Request English
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 English
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months English
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11 English
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records English
F-00385 Nurse Aide Training - Student Waiver Request English
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 English
F-00458 TDAP Cocooning Report English
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up English
F-00688 Referral to Wisconsin Birth-3 Program English
F-00478 Quality of Life Survey - Money Follows the Person (MFP) English
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04 English
F-00407 Financial Records Request English
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 English
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years English
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12 English
F-00681C Family Care - Managed Care Organization (MCO) Two (2) Options English
F-00681DDD IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options English
F-00515 Community Substance Abuse Services (CSAS) Day Treatment Service Initial Certification Application - DHS 75.12 English
F-00646 Emergency Medical Service Training Center - Training Permit Eligibility Certification English
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 English
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 English
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 English
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years English
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14 English
F-00588a PPS AODA Deskcard English
F-00681D IRIS (Include, Respect, I Self-Direct) Two (2) Consultant Agency Options English
F-00681CR Family Care - Two (2) Managed Care Organization (MCO) Options English
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 English
F-00681CC Family Care - Managed Care Organization (MCO) Three (3) Options English
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 English
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 English
F-00681DD IRIS (Include, Respect, I Self-Direct) Four (4) Consultant Agency Options English
F-00375 Yellow Fever Uniform Stamp Application English
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable English
F-00417 AODA Prevention Services Recertification Application - DHS 75.04 English
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years English
F-00472 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 English
F-00332 Medicaid Purchase Plan Premium Information / Payment English
F-00367B Age-Specific ADL / IADL Answer Choices for Cildren's Long-Term Support Programs Age: 6 - 12 Months English
F-00315B Transition Written Prior Notice English
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services English
F-00309 Medicaid Provider Report English
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months English
F-00315C Prior Notice and Consent for Evaluation and Assessment English
F-00311 Nursing Home MDS 3.0 Section Q Referral English

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Last Revised: July 28, 2017