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 Language
F-01206A IRIS One-Time Expense Vendor Bid Comparison English
F-62589 Telehealth Application – Initial Approval English
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years (PDF, 28 KB) English
F-00681CCC Family Care - Managed Care Organization (MCO) Four Options English
F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening English
F-10150B Your Rights and Responsibilities for FoodShare English
F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies English
F-13073 Compound Drug Claim English
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) English
F-11090 Mental Health Day Treatment Functional Assessment English
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography English
F-01332 Predispositional Investigation Report (PDI) English
F-01206B IRIS One-Time Expense Request - Ramp English
F-00681CR Family Care - Two (2) Managed Care Organization (MCO) Options-Rock English
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request English
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter English
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility English
F-01204C Letter - IRIS Program Notice of Action--Reduction English
F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification (PDF, 97 KB) English
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant (PDF, 30 KB) English
F-00987 EMS Service Operational Plan Advanced Skills Addendum – EMT-Basic English
F-21353 Community Options Program (COP) Exceptional Expense Request English
F-00681A Family Care - Three (3) Managed Care Organization (MCO) Options English
F-02250 Quarterly Program Integrity Report English
F-80962 New Capital Asset Record English
F-00603a PPS Core Deskcard (PDF, 20 KB) English
F-62418 Adult Day Care Initial Certification Application English
F-00473 CSAS Intervention Service Recertification Application - DHS 75.16 English
F-00264 Personal Care Agency Surveyor Guide English
F-20812 SSI-E Natural Residential Setting Application Checklist English
F-62494 Health Care Facility Construction Documentation Checklist English
F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) English
F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs English
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits English
F-62025 Report of Hours Worked - Registered Nurse / Evening English
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative English
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate English
F-00016 Wall Closure Inspection Checklist English
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) English
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool English
F-01710 Home Health Agency Initial Licensure Checklist English
F-01604 Telehealth Application – Annual Review of Approval English
F-45003 Occupational Exposure Record Per Monitoring Period (PDF, 89 KB) English
F-00989C Summary of Development - Child’s Positive Social Emotional Skills (IFSP) English
F-01283 Notification of Non-Covered Benefit Letter Template-Model English
F-44011 Application for Registration of Lead-Free or Lead-Safe Property (PDF, 52 KB) English
F-01201B IRIS Supportive Home Care / Self-Directed Personal Care / Respite Care Training Verification English
F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit English
F-00915 Wisconsin Birth to 3 Program - Data Discussion Evaluation English
F-00615 Change Project Report and Instructions English


Last Revised: July 28, 2017