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 Language
F-01812 Wisconsin Medicaid Program Nursing Home Cost Report English
F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care English
F-00688 Referral to Wisconsin Birth-3 Program English
F-20445A Individual Service Plan - Individual Outcomes English
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer English
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting English
F-02046 IRIS Financial Projections Template English
F-20394 CIP II Community Relocation Initiative 30-day / 90-day Questionnaire English
F-20448 Request for Medicaid Administrative Funds English
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors (PDF, 21 KB) English
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) English
F-10141 Wisconsin Funeral and Cemetery Aids Program Application (PDF, 635 KB) English
F-20415 CIP II Nursing Home Diversion Request Coversheet English
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care English
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request English
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program English
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter English
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter English
F-01751 Request for IMD Rebalancing Initiative Funding – Summary English
F-01655 Enrollment Discrepancy Report English
F-01319B IRIS Denial of Enrollment Request English
F-01556C IRIS Program Cost Share Letter – Repayment Plan English
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request English
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares English
F-01827 Application for Reduction of Cost Share English
F-01486 IRIS Consultant Biography English
F-01556D IRIS Program Letter – Disenrollment English
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter English
F-05291 Birth Certificate Application - Wisconsin (PDF, 1 MB) English
F-02035 Aging/ADRC Integration Funding Request Application English
F-01275A IRIS Provider Executive Staff Disclosure English
F-01939 Wisconsin Medicaid Waiver Provider Registration English
F-01442H IRIS Program Disenrollment Letter – Voluntary English
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist English
F-01556 Medicaid Cost Share Letter - Initial English
F-01545 IRIS Fiscal Employer Agent (FEA) Biography English
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter English
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter English
F-01546 IRIS Consultant Agency (ICA) Biography English
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter English
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter English
F-01596 Incident Report for CIP 1A/1B, CIP II, and COP-W Medicaid Waiver Programs English
F-01549 IRIS Certification Designation of Confidential and Proprietary Information English
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) English
F-01352 Background Check Appeal Request - IRIS Program English
F-01314 IRIS Program Employment Checklist English
F-01319 IRIS Involuntary Disenrollment Request English
F-01427 Birth to 3 Invitation to EI Team Eligibility Determination and IFSP Meeting English
F-01310 IRIS Program Conflict of Interest Disclosure – Provider English
F-01558 Risk Agreement – IRIS Program English

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Last Revised: July 28, 2017