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
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request
F-62156 Living Unit Direct Care Staff Report - Day Shift
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips
F-01952 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Giant Cell Arteritis, and Neonatal Onset Multisystem Inflammatory Disease (NOMID)
F-00107 Self-Employment Income Report
F-01814 County Agency Children’s Community Options Program (CCOP) Five-Year Plan
F-00004A Health and Employment Counseling - I Think I Need More Time
F-01210B Budget Amendment Annual Verification (BAAV) Request
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume
F-43013 Diabetes Medical Management Plan
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement
F-01270 Comprehensive Community Services Non-Traditional Approval
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-01197 Certification of Need for Specialized Medical Vehicle Transportation
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age)
F-01389A MHSIP Youth Satisfaction Survey
F-82003 Denial of Researcher Access To Health Care Records
F-20946 Recertification Assurance--COP-W / CIP II
F-62688 Feeding Assistant Training Program Trainer Application
F-16026 Prosecution Diversion Agreement
F-62447 Misconduct Incident Report
F-00588a PPS AODA Deskcard
F-11076B Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for Continuing Services
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-01938 Wisconsin EMS Paramedic Training Record - NCCP Paramedic Refresher Requirements
F-62022A Instructions for Report of Hours Worked and Resident Census Forms
F-01709 Case Management Service Plan
F-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet
F-45023 Certificate - Use of Depleted Uranium under General License
F-01542 Notification of Required Drug Testing
F-10189 Undue Hardship Bed Hold Notice
F-10097 Medicaid Income Allocation Notice
F-01349 Substitute Care Model Quality Performance Standards & Measures
F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO
F-01162 Certification of Emergency for Non-U.S. Citizens
F-00989L Summary of Services (IFSP)
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP
F-01411 Education - Medication Summary - Part B

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Last Revised: May 22, 2018