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-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment
F-62092 Hospital Certificate of Approval Application
F-01682 Wisconsin State Certified Peer Specialist Trainer Application
F-45007 Certificate of Disposition of Materials
F-00780 Options Counseling Tip Card
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-00989M Justification for Services Provided in Locations Other than Natural Environments (IFSP)
F-40303 Early Childhood Caries Prevention Screening
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11
F-11066 Prior Authorization / Oxygen Attachment (PA/OA)
F-01389 ROSI Adult Satisfaction Survey
F-22491 Consumer Report and Survey - OBVI
F-00237 Appeal Request - MCOs
F-02057 ADRC Authorization for the Release of Confidential Information
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-80130 Financial Information 
F-16038 Administrative Disqualification Hearing Notice
F-00024 HSRS Core Summary Report
F-01942B LTC FS - Request Letter
F-01285 Quarterly MCO Consolidated Financial Report Template - Model
F-62281 Care Level Change Notice
F-00681DD IRIS (Include, Respect, I Self-Direct) Four (4) Consultant Agency Options
F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources
F-00893 Affidavit of No Social Security Number - EMS Professional License
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan
F-44771AA Medicaid Targeted Case Management Face Sheet - Childhood Lead Poisoning
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA)
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents
F-02250 Quarterly Program Integrity Report
F-10141 Wisconsin Funeral and Cemetery Aids Program Application
F-80783A Family Financial Questionnaire - County Use
F-20445 Individual Service Plan - Medicaid Waivers
F-00052B Cares Data Access and Use Agreement / Designation of Cares Security and Data Exchange Coordinator
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist
F-01338 Children's Long-Term Support Parental Fee Declaration Form - Model
F-62440 Report of Hours Worked - Other Direct Care Nurse Aide / Day
F-01827 Application for Reduction of Cost Share
F-01184 Wisconsin Hemophilia Home Care Program Application
F-47141 Emergency Medical Technician-Paramedic Training Permit Application
F-00950 Notice of Denial of Medical Coverage
F-01580 Noncompliance Roster
F-44002 Asbestos Certification Application - Company
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC


Last Revised: May 22, 2018