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-47255 Emergency Medical Services Funding Assistance Program Municipal Signature and Population Verification Page
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-01634 WorkPlace Wellness Grant Program Application
F-11016 Prior Authorization Physician Attachment (PA/PA)
F-44016 Asbestos Occupant Protection Plan
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-05033 Birth Amendment - Baptismal
F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply
F-25393A Petition for Supervised Release
F-00100 State Vital Records Birth Certificate Request Letter
F-82064 Background Information Disclosure (BID)
F-01206B IRIS One-Time Expense Request - Ramp
F-20922 Determination of No Active Treatment (NAT) Rating
F-02074 Medicare Other Coverage Discrepancy Report
F-62594 Notice of Substantial Change Feeding Assistant Training Program
F-01012 Reimbursement Request for a PASRR Level I Screen
F-01934 Wisconsin EMS First Responder Training Record - First Responder Refresher Requirements
F-13151 HIPAA Privacy Amendment Request
F-47482 EMT Training Center Certification Application
F-00596a PPS Mental Health Deskcard
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion
F-11035 Prior Authorization Dental Request Form (PA/DRF)
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years
F-01319B IRIS Denial of Enrollment Request
F-05291 Wisconsin Birth Certificate Application
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement
F-00681DDDL IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options (Large Print)
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum
F-01226 WISEWOMAN Lifestyle Program Follow-Up
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice
F-21080A Children's Long-Term Support (CLTS) Waivers Application Checklist - Step Two
F-02118 Authorized Signer Designation for Access to PPS and FSIA
F-62652 Home Health Agency Licensure Survey Home Visit Guide
F-01068B General Pediatric Clinic - 6 to 8 Week Visit
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization
F-62026 Report of Hours Worked - Nurse Aide / Evening
F-00660A Client Rights Office Consult Question
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire
F-11066 Prior Authorization / Oxygen Attachment (PA/OA)
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP)
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-40092 Physical Activity Zone
F-02390 Fall Medicare Training Participant Survey
F-00191A Certified Outpatient Clinic Request for a School Branch Office
F-01204B Letter - IRIS Program Notice of Action - Limit

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Last Revised: May 22, 2018