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 Division Other Location
F-13074 Pharmacy Special Handling Request DMS
F-00987D EMS Service Operational Plan Advanced Skills Addendum (Paramedic) DPH
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-00543A File Review Checklist DMS
F-47119 Ambulance Report DPH
F-01624 OARS Alternative to Revocation (ATR) Referral DCTS
F-02590 Ongoing Review of Nonresidential Group Supported Employment Site Surveys DMS
F-05043 Notice of Removal - Corpse (Hospital, Nursing Home, Hospice) DPH
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment DPH
F-01319B IRIS Denial of Enrollment Request DMS
F-00950A Notice of Denial of Medical Coverage – PACE DMS
F-00044 User Agreement for System Access DES
F-01407 Checklist (Asthma Care and Environmental Strategies) DPH
F-22491 Consumer Report and Survey - OBVI DPH
F-02284 Record of School Employee Examination DPH
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit DMS
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS
F-02046 IRIS Financial Projections Template DMS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System DMS
F-47471 Emergency Medical Technician Verification of Licensure DPH
F-01593A Civil Money Penalty (CMP) Funded Project Report DQA
F-02110D RCAC: New Provider Certification / Registration Application Checklist DQA
F-10080 SeniorCare Authorization of Representative DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-44003 Lead-Safe Renovator Application DPH
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) DMS
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS
F-01210A IRIS Budget Amendment Provider Quote Comparison DMS
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) DPH
F-01413 Post-Assessment Questionnaire DPH
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-16014 Notice of Program Violation DMS
F-01068J General Pediatric Clinic - Preschool Visit DMS
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report DQA
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-00676 Youth Transition Pretest DPH
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) DPH
F-00974 Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor DPH
F-10114 Medicaid Disability Redetermination Report DMS
F-00375 Yellow Fever Uniform Stamp Application DPH
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-01556D IRIS Program Letter – Disenrollment DMS

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Last Revised: March 26, 2019