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 Languagesort descending
F-80462 Capital Asset Summary English
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets English
F-01285 Quarterly MCO Consolidated Financial Report Template - Model English
F-20980 Assessment / Supplement to the Long Term Care Functional Screen English
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire English
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation English
F-00221B Family Care / Partnership / PACE / IRIS - Refusal to Accept Services and MCO Requested Disenrollment Routing English
F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification (PDF, 97 KB) English
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request (PDF, 163 KB) English
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) English
F-47225 Report of Enforcement Methods (Part 1) English
F-00015 Final Occupancy Inspection Checklist English
F-11047 Wisconsin Medicaid - Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 (PDF, 24 KB) English
F-44257 Wisconsin Immunization Record Card (PDF, 114 KB) English
F-02109 Community-Based Residential Facility (CBRF) English
F-01321 Lyme Disease Case Report - Wisconsin (PDF, 378 KB) English
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member English
F-10098 Medicaid Member Asset Allocation Notice English
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program (PDF, 32 KB) English
F-01999 Foster Grandparent Program – State Match Funding Application English
F-80882 Contract Summary (CARS) English
F-00478 Quality of Life Survey - Money Follows the Person (MFP) English
F-01338 CLTS Parental Fee Declaration-Model English
F-21150A Adult Protective Services (APS) Investigation Transfer - Model English
F-01733 FoodShare Outreach Project Proposal English
F-62504 Community Substance Abuse Services (CSAS) or Mental Health Clinic Initial Certification Application English
F-00263 Personal Care Agency Record Review English
F-01185 Wisconsin Adult Cystic Fibrosis Program Application English
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) English
F-01556C IRIS Program Cost Share Letter – Repayment Plan English
F-47463B Emergency Medical Techician (EMT) - Basic Operational Plan Components (PDF, 26 KB) English
F-00047 Designated Asbestos Coordinator (PDF, 39 KB) English
F-11081 Wisconsin Medicaid Rural Health Clinic Provider Staff Encounters English
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels English
F-02230 County Agency Children's Community Option Program (CCOP) Annual Plan Update English
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen English
F-00916 AIDS Drug Assistance Program / Chronic Disease Program / Well Woman Program Provider File Updat Request English
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) English
F-40093 Annual ROSIE User Security and Confidentiality Agreement English
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E) English
F-82003 Denial of Researcher Access To Health Care Records (PDF 14 KB) English
F-00534 PACE / Partnership Member Requested Disenrollment English
F-01506 Medical Supply and Equipment Vendor Terms of Reimbursement (PDF, 34 KB) English
F-21365 Comprehensive Community Services Startup Outcomes - 2009 English
F-44212 School Report to the District Attorney (PDF, 42 KB) English
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan English
F-00315A Written Prior Notice - No Evaluation Recommended English
F-01203 IRIS Provider Education - Health and Safety – Incident Reporting English
F-16029 FoodShare Wisconsin Repayment Agreement English
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup English


Last Revised: July 28, 2017