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-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities
F-21077 Autism Treatment Services Criteria Checklist Instructions
F-16076 FoodShare Six-Month Report and Instructions
F-00164 Civil Rights Compliance Plan
F-01206B IRIS One-Time Expense Request - Ramp
F-02284 Record of School Employee Examination
F-02086 Histoplasmosis Case Worksheet
F-80025 Forms / Publications Order
F-00851 AIDS/HIV Drug Assistance and Insurance Assistance Programs - Six-Month Verification
F-02047 IRIS Financial Reporting Template
F-00191 Certified Outpatient Clinic Request for a Branch Office
F-62069 Home Health Agency Complaint Report
F-47125 Emergency Medical Technician - Intermediate Training Permit Application
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request
F-01153 Breast Pump Order
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs
F-10126 Appoint, Change, or Remove an Authorized Representative
F-01761 Intoxicated Driver Program Self-Evaluation
F-01170 Written Correspondence Inquiry
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-44746 Farmers Market Nutrition Program (FMNP) - Site Observation Worksheet
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment
F-01454 IRIS Program Withdrawal Letter – No Progress
F-00367B Age-Specific ADL / IADL Answer Choices for Cildren's Long-Term Support Programs Age: 6 - 12 Months
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s)
F-00115 Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-02205 EMS Instructor II Evaluation
F-80952A Contingency Plan - DHS Regional Offices
F-62418 Adult Day Care Initial Certification Application
F-20922 Determination of No Active Treatment (NAT) Rating
F-62657 Home Health Agency Contract Review Worksheet
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
F-01283 Notification of Non-Covered Benefit Letter Template - Model
F-16026 Prosecution Diversion Agreement
F-01068H General Pediatric Clinic - 18 Month Visit
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34
F-11076C Prior Authorization / Residential Care Center Treatment Attachment (PA/RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other
F-10189 Undue Hardship Bed Hold Notice
F-01442i IRIS Program Disenrollment Letter - Cancelled
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-60309 Self-Supervision Evaluation and Waiver Request
F-01710 Home Health Agency Initial Licensure Checklist
F-01003 Wisconsin Medicaid Certification of Public Expenditures
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope

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Last Revised: May 22, 2018