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-02118 Authorized Signer Designation for Access to PPS and FSIA
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA)
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB)
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review
F-62027 Report of Hours Worked - Registered Nurse / Night
F-05102 Wisconsin Immunization Registry Exclusion
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP)
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-22018 HSRS Long-Term Support Module - Module Type A
F-02107 Family Adult Day Care Center
F-80013 Petty Cash Fund Annual Report
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
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips
F-16029 FoodShare Wisconsin Repayment Agreement
F-02011 Fluoride Mouthrinse Program Annual Report
F-62224 Nurse Aide Training Program – Notice of Substantial Change
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility
F-00036 Power of Attorney for Finance and Property
F-01726 Basic Equipment List for Nurse Aide Training Programs
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License
F-01275 IRIS Provider Board Member Disclosure
F-01556D IRIS Program Letter – Disenrollment
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up
F-01361 ForwardHealth Provider Express Enrollment Change of Address
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
F-22564 Authorization for Retroactive Caretaker Supplement (CTS)
F-02217 Affidavit for Supplemental Nutrition Assistance Program – Puerto Rico
F-80477A Canteen Operations Analysis of Cash - GAAP Basis
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA)
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-62333 Plan Approval Application and Instructions
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application
F-00054 Request for Waiver of Education / Experience Requirements (ADRC)
F-44212 School Report to the District Attorney
F-45038 Wisconsin Mercury Exposure Study
F-01314 IRIS Program Employment Checklist
F-01319 IRIS Involuntary Disenrollment Request
F-00714 Business Associate Agreement - County or Tribal Contract

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Last Revised: May 22, 2018