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-00596a PPS Mental Health Deskcard
F-01950 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-62158 Living Unit Direct Care Staff Report - Night Shift
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels
F-11285 HealthCheck Screener Affirmation
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA)
F-10141 Wisconsin Funeral and Cemetery Aids Program Application
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse
F-01668 Consent for Participation in Veterans Outreach and Recovery Program (VORP)
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification
F-01389A MHSIP Youth Satisfaction Survey
F-22565 Authorization for Recoupment Caretaker Supplement
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey
F-20987 Authorized Representative Designation, Medicaid Community Waiver Programs
F-00021 HealthCheck Referral
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-82006 Employment Application and Resume
F-02118 Authorized Signer Designation for Access to PPS and FSIA
F-62696 Student Nurse / Graduate Nurse Verification
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-01319 IRIS Involuntary Disenrollment Request
F-16034 Self-Employment Income Worksheet - Corporation
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-62023 Report of Hours Worked - Registered Nurse / Day
F-01205D IRIS Participant Education: Program Integrity - Fraud Prevention
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA)
F-01287 Template for Transition - Initial Plan - Model
F-00950 Notice of Denial of Medical Coverage
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records
F-01937 Wisconsin EMS Paramedic Training Record - Paramedic Refresher Requirements
F-42014 Acuity Index
F-01542 Notification of Required Drug Testing
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-00989L Summary of Services (IFSP)
F-42010 Interjurisdictional Tuberculosis Notification
F-29320 COP Cost-Share Worksheet #1 Instructions
F-00309 Medicaid Provider Report
F-01159 Commerical Other Coverage Discrepancy Report
F-00107 Self-Employment Income Report
F-01442G IRIS Program Disenrollment Letter – Non-Spending
F-00681CL Family Care - Managed Care Organization (MCO) Two Options (Large Print)

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Last Revised: May 22, 2018