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-40096 eWIC Program Repayment Agreement
F-40074 Annual Physical Activity Record
F-40063 TEFAP / CSFP Commodities Complaint
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program
F-40075 Pedometer Walking Program
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-40076 Women, Infants, and Children (WIC) Nutrition Program Income Statement
F-40040 Envelope - Vendor and Integrity Unit #9
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report
F-40041 Certification and Food Package Pick-Up
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-40071 Children's Physical Activity Chart
F-40108 Retail Vendor Application Amendment WIsconsin Women, Infant, and Children (WIC) Program
F-40092 Physical Activity Zone
F-00046 Family Care Program - Enrollment
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application
F-40072 8 Week Activity Log
F-40117 Abortion Information Provision Certification
F-40019 Affirmation of Identity, Residency, and/or Income
F-26100 Client Rights Limitation or Denial Documentation
F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement
F-29314 COP Declaration of Income and Assets and State Residency
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant
F-02047 IRIS Financial Reporting Template
F-29323 Hardship Policy / Hidden Asset Policy
F-25904 Admission to Caseload - Revocation
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC
F-02306 Application for Telecommunication Assistance Program (TAP)
F-01939 Wisconsin Medicaid Waiver Provider Registration
F-01338 Children's Long-Term Support Parental Fee Declaration Form - Model
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-02050 Coordinated Services Teams (CST) Final Expenditure Report
F-02000 ADRC/Aging System User: Access/Delete/Change
F-19002 Request to Reduce QUEST Card Balance
F-16014 Notice of Program Violation
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-24277 Informed Consent for Psychotropic Medication
F-62236 Hospice Clinical Record Review
F-25180 Order of Discharge Upon Expiration of Commitment
F-25614 Conditional Release Rules and Conditions
F-25206 Petition for Capias
F-25207 Order Granting Capias
F-25213 Admission to Caseload - Mental Health
F-21343A Alzheimer's Family and Caregiver Support Program (AFCSP) Financial Eligibility Screen - Worksheet 1
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-22638 Notification of Waiver Program Termination


Last Revised: May 22, 2018