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-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request
F-21225A Program Participation System (PPS): B-3 Module
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA)
F-01068G General Pediatric Clinic - 15 Month Visit
F-16006 FoodShare Wisconsin Change Report
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis
F-62062 Hospice License Application
F-05260 Letter of Non-Marriage Application
F-00685 Statement of Tribal Affiliation
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra®
F-44824 Wisconsin Day Care Assessment
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-00417 AODA Prevention Services Recertification Application - DHS 75.04
F-00989J Transition Plan - Turning 3 Years Old (IFSP)
F-40108 Retail Vendor Application Amendment WIsconsin Women, Infant, and Children (WIC) Program
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery
F-01207A IRIS Fiscal / Employer Agent Quality Management Plan Tracking
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request
F-22433 Request for a Hearing, Wisconsin Birth to 3 Program
F-02110 Residential Care Apartment Complex (RCAC)
F-00005 Senior FMNP Agency Application to Participate
F-80112 Vendor Validation
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-16033 FoodShare Worksheet
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES)
F-62233 Hospice Personnel Record Review
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member
F-01708 Case Management Comprehensive Assessment
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators
F-01282 Monthly Enrollment Discrepancy Report Template - Model
F-00476 CARES Automated Systems Access Request
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results
F-01112 HealthCheck Verification Card
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS)
F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI)
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases
F-00042 Knowledge Journal
F-80751 Non-County Resident Proceedings Cost Certification
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs
F-20397 Telecommunications Assistance Program (TAP) Voucher
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request
F-10139 BadgerCare Plus Premium Information / Payment


Last Revised: May 22, 2018