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-01205B IRIS Participant Education: Budget Amendments
F-01205C IRIS Participant Education: One-Time Expense Requests
F-01205J IRIS Participant Education: Self-Directed Personal Care
F-01020 Nursing Home Care Determination Request
F-11237 Specialized Medical Vehicle Providers Affidavit
F-02008 CLTS Waivers Certification Exam
F-021343G AFCSP Fiscal Report
F-62546 Corporate Guardianship Program Annual Report
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities
F-40085 WIC Program Notice of Ineligibility
F-02040 WIC Program Notice of Categorical Ineligibility
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification
F-80025 Forms / Publications Order
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-10161 Statement of Citizenship and/or Identity
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents
F-10126 Appoint, Change, or Remove an Authorized Representative
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application
F-10114 Medicaid Disability Redetermination Report
F-62447 Misconduct Incident Report
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site
F-02341A Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration
F-02331 Caregiver Programs Customer Satisfaction Survey
F-21276 DCTS Annual Grant/Contract Application
F-02250 Quarterly Program Integrity Report
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events
F-80112 Vendor Validation
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information
F-25393A Petition for Supervised Release
F-82009AA Confidential Information Release Authorization - Katie Beckett Program
F-82002 Denial of Government Access To Health Care Records
F-82021 Researcher's Request for Confidential Records or Human Subjects Research
F-82003 Denial of Researcher Access To Health Care Records
F-82006 Employment Application and Resume
F-82009 Confidential Information Release Authorization - Generic 
F-80976 Employment and Education History Summary
F-80911 Limited Term Employment (LTE) or Project Employment Application
F-80479 Audit Confirmation Request
F-80751 Non-County Resident Proceedings Cost Certification
F-80761 Contingent Account Activity Report
F-80783A Family Financial Questionnaire - County Use
F-00615A Change Project Summary and Instructions
F-16038 Administrative Disqualification Hearing Notice
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-80459 Client Account Balance Report
F-62654 Home Health Agency Licensure Survey Exit Conference Guide
F-62594 Notice of Substantial Change Feeding Assistant Training Program

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Last Revised: March 26, 2019