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-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard
F-20985 Participant Rights and Responsibilities Notification
F-20922 Determination of No Active Treatment (NAT) Rating
F-20987 Authorized Representative Designation, Medicaid Community Waiver Programs
F-20941 Informed Consent for Participation in Wisconsin's Money Follows the Person (MFP) Demonstration
F-10112 Medicaid Disability Application
F-21076 Informed Consent - Children's Long-Term Support Functional Screen
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice
F-21042 Medicaid Denial Chart
F-20941A Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration
F-21055 Home Modification Request for a Ramp
F-21189 Rights of Detention
F-20942A Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet
F-21078 Children's Long-Term Support (CLTS) Waivers Recertification Checklist
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home / Institution
F-21080 Children's Long-Term Support (CLTS) Waivers Eligibility Verification - Step One
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses
F-20818 Certification for SSI-E Exceptional Expense Supplement
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-20823 COP Functional Screen
F-20810 Medicaid Waiver Program Health Report
F-20812 SSI-E Natural Residential Setting Application Checklist
F-20465 Declaration of Income
F-00219 Self-Employment Income Report: Farm Business
F-20817 Assessment Worksheet for Natural Residential Setting
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-10150A Your Rights and Responsibilities for Health Care
F-16073 FoodShare Wisconsin Nonfinancial Worksheet
F-16076 FoodShare Six-Month Report and Instructions
F-20445A Individual Service Plan - Individual Outcomes
F-10139 BadgerCare Plus Premium Information / Payment
F-02053 ADRC Referral to Income Maintenance
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request
F-20448 Request for Medicaid Administrative Funds - Staff Position
F-44819 Farmers Market Nutrition Program (FMNP) - Application for Farmstands
F-16104 Local Agency Customer Feedback
F-20452 Criteria for High Risk of Nursing Home Admission
F-20009 Complaint Report
F-16105 Disaster FoodShare Notice of Decision
F-16015 Notice of Approval of Benefits/Positive Change in Benefits
F-16033 FoodShare Worksheet
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB)
F-16034 Self-Employment Income Worksheet - Corporation
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits

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Last Revised: May 22, 2018