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 Division Other Location
F-02587 Children's Long-Term Support (CLTS) Waiver Program Deciding Together Implementation Planning Tool DMS
F-02573 Prior Authorization Drug Attachment for Wakix DMS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-02403 Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment DPH
F-02588 Financial Exploitation Tracking for Counties DPH
F-02250 Quarterly Program Integrity Report OIG
F-10076 SeniorCare Application DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-02574 Wisconsin Assistive Technology Advisory Council Application DPH
F-01421 WISEWOMAN Monthly Reporting for Direct Services DPH
F-02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH
F-02562 Disability Benefit Specialist Program Client Services Agreement DPH
F-01781 Immunization Program Functional Exercise 2018-2020 (BP1 Supplemental) DPH
F-02583 Options Counseling Record Review Tool DPH
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request DPH
F-11133 Personal Care Screening Tool (PCST) DMS
F-16033 FoodShare Worksheet DMS
F-01218 WISEWOMAN Client Consent DPH
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-01219 WISEWOMAN Health History Assessment DPH
F-00688 Referral to Wisconsin Birth to 3 Program DMS
F-62592 Feeding Assistant Training Program Annual Review Report DQA
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 DQA
F-62504 Behavioral Health Certification Section: Initial Certification Application DQA
F-25180 Order of Discharge Upon Expiration of Commitment DCTS
F-02541 Wisconsin Birth Defects Condition Nomination DPH
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-29314 COP Declaration of Income and Assets, and State Residency DPH
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site DMS
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy DPH
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement DPH
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-62610 Nurse Aide Training Program Primary Instructor Application DQA
F-62687 Nurse Aide Training Program - Trainer Application DQA
F-00923 Reschedule Lead (PB) Certification Exam DPH
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information DMS
F-47255 Emergency Medical Services Program Municipal Signature and Population Verification DPH
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36 DQA
F-00476 CARES Automated Systems Access Request DMS
F-01710 Home Health Agency Initial Licensure Checklist DQA

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Last Revised: March 26, 2019