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-47128 Emergency Medical Technician - Basic Training Permit Application (PDF, 711 KB) English
F-01586 Medical Stockpile Access Request (PDF, 247 KB) English
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) English
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers English
F-10147 Wisconsin Veterans Home at King - Medicaid Review (PDF, 253 KB) English
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) (PDF, 200 KB) English
F-01314 IRIS Program Employment Checklist English
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest English
F-01549 IRIS Certification Designation of Confidential and Proprietary Information English
F-01418 21-Day Monitoring Period Chart (PDF, 323 KB) English
F-40063 The Emergency Food Assistance Program (TEFAP) Commodities Complaint English
F-01219 WISEWOMAN Health History Assessment English
F-00262A Personal Care Agency Application Regulatory Guidance Checklist English
F-22638 Notification of Waiver Program Termination English
F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2 English
F-21063 Exception to Care Management / Support and Service Coordination Contact Requirements English
F-16039 Waiver of Administrative Disqualification Hearing English
F-00963 Children’s Long Term Support Reconciliation Packet English
F-13149 Wisconsin Medicaid HIPAA Privacy Accounting Request (PDF, 152 KB) English
F-00676 Youth Transition Pretest English
F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 English
F-02106 Adult Day Care Center English
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers English
F-00052 Aging and Disability Resource Center (ADRC) Application English
F-62608 Request for Use of Medical Restraints English
F-01767 TEFAP Shelter Self-Assessment Tool English
F-62274A Personal Care Agency Consent for Home Visit Spanish
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) English
F-47463D Emergency Medical Techician (EMT) - Intermediate Operational Plan Components (PDF, 26 KB) English
F-11130 Federally Qualified Health Center Interim Report English
F-45021 Generally Licensed Device Inspection by Mail English
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) 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-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report English
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume English
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter English
F-42017 Wisconsin Initial Refugee Health Assessment English
F-01389A MHSIP Youth Satisfaction Survey English
F-29323 Hardship Policy / Hidden Asset Policy (PDF, 17 KB) English
F-00221A Family Care / Partnership / PACE / IRIS Change Routing English
F-01278 Program Participation System (PPS) Employment Questions English
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) English
F-01200 IRIS Program Cost Share Repayment Agreement English
F-20891 Intoxicated Driver Program Supplemental Funding Request English
F-00076 Variance Request - Wait List English
F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit English
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation English
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter English
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results (PDF, 95 KB) English
F-01389B Mental Health Statistical Improvement Program (MHSIP) Family Satisfaction Survey English

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Last Revised: July 28, 2017