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-01700 Exception-to-Policy Request (AIDS/HIV)
F-44757 WIC Farmer's Market Contract For Farmers
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-11090 Mental Health Day Treatment Functional Assessment
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP)
F-40073 Monthly Physical Activity Sheet
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs
F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Providers
F-10137 Medicaid Change Report
F-01359 Historical Earnings Verification Request
F-21080A Children's Long-Term Support (CLTS) Waivers Application Checklist - Step Two
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-01310 IRIS Program Conflict of Interest Disclosure – Provider
F-69259 Long Term Care Facility Application For Medicare and Medicaid CMS-671
F-01146 Wisconsin Chronic Disease Program Provider Data Sheet
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer
F-62158 Living Unit Direct Care Staff Report - Night Shift
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program
F-44161A WIC Cardholder Rights and Responsibilities
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required)
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12
F-11285 HealthCheck Screener Affirmation
F-01275A IRIS Provider Executive Staff Disclosure
F-40310 Adult Oral Health Screening (PDF, 176 KB)
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents
F-10162 Verification of Veterans Benefits
F-82009AA Confidential Information Release Authorization - Katie Beckett Program
F-21343E Alzheimer's Family and Caregiver Support Program (AFCSP) General Information
F-02341 County Waiver Agency Contact: Wisconsin Children's Long-Term Support (CLTS) Waiver Provider SharePoint Site
F-00016 Wall Closure Inspection Checklist
F-01812 Wisconsin Medicaid Program Nursing Home Cost Report
F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2
F-02080 Dementia Crisis Innovation Grants: Round Two
F-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement
F-62318 Hospice Quality Assessment and Performance Improvement Review
F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program
F-45022 Application for Material License
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice
F-00714 Business Associate Agreement - County or Tribal Contract
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs
F-11008 Prior Authorization / Therapy Attachment (PA/TA)
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA)
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-02282A Resident Relocation Plan
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s)
F-05027A Report of Citizenship
F-80900 Receivables Annual Report

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Last Revised: May 22, 2018