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-80190 Travel Reimbursement Request Non-State Employee
F-44019A Immunization Assessment
F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request
F-62157 Living Unit Direct Care Staff Report - Evening Shift
F-11237 Specialized Medical Vehicle Providers Affidavit
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years
F-10126 Appoint, Change, or Remove an Authorized Representative
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information
F-01949 ADRC Annual Update
F-00113 Four Conditions for the Use of Funding in a CBRF
F-01827 Application for Reduction of Cost Share
F-00004 Health and Employment Counseling Application
F-01628 OARS Enrollment Letter
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-01275 IRIS Provider Board Member Disclosure
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age
F-00889 Designation of Confidential and Proprietary Information - Managed LTC Business Plan
F-02390 Fall Medicare Training Participant Survey
F-01389B MHSIP Family Satisfaction Survey
F-02285 Pilot of Kindergarten Public Health Report, 2017-18
F-82006 Employment Application and Resume
F-02140 Urgent Services Agreement
F-20980 Assessment / Supplement to the Long Term Care Functional Screen
F-62692 Feeding Assistant Training Program Primary Instructor Application
F-16028 Notice of FoodShare Overissuance
F-62457 Request for Permission to Start Construction for Footings and Foundations
F-13039 Estate Recovery Program (ERP) Disclosure
F-00596 PPS Mental Health Module
F-11076C Prior Authorization / Residential Care Center Treatment Attachment (PA/RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12
F-00334 Money Follows the Person (MFP) - Participant Reporting
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program
F-02034 Aging/ADRC Integration Funding Budget Worksheet
F-01930 Minority Health Advisory Group Nomination and Agreement
F-62023 Report of Hours Worked - Registered Nurse / Day
F-00681DD IRIS (Include, Respect, I Self-Direct) Four (4) Consultant Agency Options
F-01644 Parents Who Host, Lose The Most Application
F-10098 Medicaid Member Asset Allocation Notice
F-01350 Initial / Recertification Service Plan Checklist
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC
F-01164 Consent for Sterilization


Last Revised: May 22, 2018