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-11237 Specialized Medical Vehicle Providers Affidavit
F-45015 Application for Radioactive Material License for Broad Scope
F-00478 Quality of Life Survey - Money Follows the Person (MFP)
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare
F-42023 Vaccine Celsius Temperature Log
F-00261 Personal Care Agency Personnel Record Review
F-00681C Family Care - Managed Care Organization (MCO) Two (2) Options
F-01348A Ratio Method, Add-On Indirect Care Management Support Costs Worksheet
F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI)
F-02205 EMS Instructor II Evaluation
F-00042 Knowledge Journal
F-80761 Contingent Account Activity Report
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation
F-02026 Ethnicity and Race Selection
F-62373 Resident Evacuation Assessment
F-00917 Provider Enrollment Application Process
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs
F-12023 Birth to Three Program Exemption Request Information and Instructions
F-47125 Emergency Medical Technician - Intermediate Training Permit Application
F-00534 PACE / Partnership Member Requested Disenrollment
F-01588 Application for Available Beds
F-10188 Undue Hardship Waiver Decision for Facility
F-44000 Tuberculosis Disease Initial Request for Medication
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting
F-05021C Report of Legal Name Change - Confidential
F-25527 Request for Increased Contract Allocation
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-00059 Outpatient Mental Health Clinic Application - DHS 35
F-80983 Civil Rights Complaint
F-01205A IRIS Participant Education: Health and Safety - Incident Reporting
F-20812 SSI-E Natural Residential Setting Application Checklist
F-02040 WIC Program Notice of Categorical Ineligibility
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation
F-00987C EMS Service Operational Plan Advanced Skills Addendum (First Responder)
F-01803 Maternal Referral / Communication Wisconsin WIC Program
F-13066 Claim Refund
F-47463C Intermediate Technician Operational Plan Components
F-00568 EMS Board Sub-Committee Appointment Application
F-01646 AIDS/HIV Assistance and Insurance Assistance Program Insurance Enrollment Report (PDF, 193 KB)
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses
F-44089 Wisconsin WIC Checks Accepted Here - Stickers
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-05045 Report for Final Disposition
F-29323 Hardship Policy / Hidden Asset Policy
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies
F-00119 Personal Care Agency Application for Approval

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Last Revised: May 22, 2018