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-01209 IRIS Certification Acknowledgment
F-62319 Hospice Volunteer Program Review
F-00681DDD IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement
F-47181 First Responder Certification Card
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request
F-01570 Ice Arena Equipment Maintenance Log
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application
F-44018 Request for Repairs
F-11035 Prior Authorization Dental Request Form (PA/DRF)
F-01430 Prior Authorization Drug Attachment for Xyrem®
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years
F-29320 COP Cost-Share Worksheet #1 Instructions
F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents Renewal
F-05291 Wisconsin Birth Certificate Application
F-80900 Receivables Annual Report
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-20985 Participant Rights and Responsibilities Notification
F-01989 Renewal Application – Individual Lead Disciplines
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment
F-62494 Health Care Facility Construction Documentation Checklist
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request
F-01068E General Pediatric Clinic - 9 Month Visit
F-47461A Label-Wash
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request
F-44192 Child Care Immunization Record
F-00681 Partnership - Three (3) Managed Care Organization (MCO) Options
F-44444 WIC Vendor Supply Order
F-11066 Prior Authorization / Oxygen Attachment (PA/OA)
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-00407 Financial Records Request
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-10110 Medicaid/BadgerCare Plus Eligibility Certification
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research
F-00202 Individual Service Plan - Community Recovery Services (CRS)
F-21189 Rights of Detention
F-83271 DHS Website Feedback
F-01286 Template for Transition - Final Plan
F-62589 Telehealth Application – Initial Approval
F-00004 Health and Employment Counseling Application
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification
F-47478 First Responder / Emergency Medical Technician Application Electronic Addition to a Roster
F-01205M IRIS Participant Education: Restrictive Measures
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan
F-00726 Typical Vision Developmental Milestones

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Last Revised: July 28, 2017