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
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA)
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP)
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services
F-01749 Prior Authorization / Preferred Drug List (PA/PDL) for Hypoglycemics, Insulin – Long-Acting
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review
F-01708 Case Management Comprehensive Assessment
F-01827 Application for Reduction of Cost Share
F-01729 Nonprobate Asset / Property Disclosure
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement
F-01709 Case Management Service Plan
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review
F-01700 Exception-to-Policy Request (AIDS/HIV)
F-01648 Coverdell Stroke Care Partner Agreement
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra®
F-01661 Letter – Foster Care Termination
F-01649 Coverdell Stroke Champion Partner Agreement
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review
F-01733 FoodShare Outreach Project Proposal
F-02287 Vaccine Return - Request for Authorization to Return
F-02271 Coordination of Confirmatory Testing Agreement
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers
F-01542 Notification of Required Drug Testing
F-01402 Test Your Knowledge About Trauma-Informed Care
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-01596 Incident Report for CIP 1A/1B, CIP II, and COP-W Medicaid Waiver Programs
F-01481 Marriage Record Amendment Request Officiant Affidavit
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-01598 Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents
F-01394 Virginia Graeme Baker Act – Drain Cover Replacement Log
F-01586 Medical Stockpile Access Request
F-01454 IRIS Program Withdrawal Letter – No Progress
F-01398 WISEWoman Client Home Blood Pressure Monitoring Agreement
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-01410 Education - Medication Summary - Part A
F-01423 AIDS/HIV Drug Assistance and Insurance Assistance Program Market Place Enrollment Report
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-00388 County Birth to 3 Fiscal Reconciliation Report
F-01430 Prior Authorization Drug Attachment for Xyrem®
F-01427 Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting
F-01418 21-Day Monitoring Period Chart
F-01604 Telehealth Application – Annual Review of Approval
F-01411 Education - Medication Summary - Part B
F-01557 Pool and Water Attractions Operator Survey
F-01406 Asthma Care (Release of Information )


Last Revised: July 28, 2017