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-62333 Plan Approval Application and Instructions DQA
F-01939 Wisconsin Medicaid Waiver Provider Registration DMS
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH
F-45025 Patient Questionnaire DPH
F-01588 Application for Available Beds DMS
F-02538A CLTS Provider Cost-Based Outlier DMS
F-13151 HIPAA Privacy Amendment Request DMS
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine DPH
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-00315C Prior Notice and Consent for Evaluation and Assessment DMS
F-22553A Free In-Service or Educational Training Request DPH
F-80882 CARS Contract Variance Correction DES
F-44160A WIC Plastic Cover for WIC ID Folder (order in multiples of 200) DPH
F-05102 Wisconsin Immunization Registry Opt-out Request DPH
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-62500 Health Care Facility Fire Report DQA
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-01949 ADRC Annual Update DPH
F-01020 Nursing Home Care Determination Request DMS
F-47242 Asbestos Certification Application DPH
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement DPH
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization DMS
F-00596a PPS Mental Health Deskcard DCTS
F-44010 Lead-Free / Lead-Safe Property Registry, Training Course, Class and Roster Database Access Application DPH
F-01454E IRIS Program Withdrawal Letter – Voluntary DMS
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet DQA
F-11048 Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS
F-00367B Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months DMS
F-25206 Petition for Capias DCTS
F-82009 Confidential Information Release Authorization - Generic  DES
F-02258 Minority Health Advisory Committee Application DPH
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS
F-00101 Authorization to Request Birth Records DMS
F-62601 Rights of Home Health Agency Patients DQA
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-01942B LTC FS - Request Letter DMS
F-01068G General Pediatric Clinic - 15 Month Visit DMS
F-47479 Trauma Care Facility Classification Application DPH
F-01642 OBVI Orientation and Mobility Screening DPH
F-16024 FoodShare Notice of Disqualification DMS
F-00676 Youth Transition Pretest DPH
F-44161 WIC Rights and Responsibilities DPH
F-01546 IRIS Consultant Agency (ICA) Biography DMS
F-02466 MCO Appeal Log for Family Care, Family Care Partnership, and PACE Programs DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-00386 Nurse Aide Training Program – Application for ADA Accommodation During Nurse Aide Testing DQA
F-40041 Certification and Food Package Pick-Up DPH

Pages

Last Revised: March 26, 2019