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
F-00889 Designation of Confidential and Proprietary Information - Managed LTC Business Plan
F-02288 WisCaregiver Career Program – Registration Agreement
F-82064 Background Information Disclosure (BID)
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement
F-80013 Petty Cash Fund Annual Report
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist
F-20891 Intoxicated Driver Program Supplemental Funding Request
F-62569 Individual Provider Status Approval Application and Supervisor Affidavit
F-62156 Living Unit Direct Care Staff Report - Day Shift
F-00596 PPS Mental Health Module
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication
F-00334 Money Follows the Person (MFP) - Participant Reporting
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire
F-01749 Prior Authorization / Preferred Drug List (PA/PDL) for Hypoglycemics, Insulin – Long-Acting
F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers
F-01649 Coverdell Stroke Champion Partner Agreement
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required)
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP)
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse
F-40104 WIC Retail Vendor Annual Food Sales Survey
F-01348B Itemized Method, Administration and Support Staff Worksheet
F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-01164 Consent for Sterilization
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-01204A Letter - IRIS Program Notice of Action - Denial
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-80921 Invoice Request (PRINT ON BUFF PAPER)
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-62687 Nurse Aide Training Program Trainer Application
F-20445 Individual Service Plan - Medicaid Waivers
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request
F-00777 MAPT Vendor Related Allocation Formula
F-11289 HealthCheck County Outreach Case Management Plan for County
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-62381 Residential Care Apartment Complex Regulations Compliance Statement
F-01942C LTC FS - Release of Information Authorization
F-62457 Request for Permission to Start Construction for Footings and Foundations
F-01804 Appointment Results Wisconsin WIC Program
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care


Last Revised: July 28, 2017