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-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request
F-00989G Tell Us About Your Family (IFSP)
F-43016 Prevent Heart Disease & Stroke Wallet Card
F-11248 Services that cannot be Billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2)
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10
F-01204E Letter - IRIS Program Notice of Action - Functional Eligibility
F-25206 Petition for Capias
F-10161 Statement of Citizenship and/or Identity for Special Populations
F-02107 Family Adult Day Care Center
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other
F-80025 Forms / Publications Order
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-01352 Background Check Appeal Request - IRIS Program
F-02011 Fluoride Mouthrinse Program Annual Report
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail
F-01200 IRIS Program Cost Share Repayment Agreement
F-01733 FoodShare Outreach Project Proposal
F-47125 Emergency Medical Technician - Intermediate Training Permit Application
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet
F-01275A IRIS Provider Executive Staff Disclosure
F-44016 Asbestos Occupant Protection Plan
F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model
F-00546 Community Support Program (CSP) for Persons with Chronic Mental Illness Initial Certification Application - DHS 63
F-00219W Self-Employment Income Report: Farm Business Worksheet
F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP
F-10193 Undue Hardship Waiver Request
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility
F-00321 OBVI Initial Interview Assessment
F-80751 Non-County Resident Proceedings Cost Certification
F-20946 Recertification Assurance--COP-W / CIP II
F-05024 Voluntary Paternity Acknowledgement
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-00098 Summary of Information Letter
F-62457 Request for Permission to Start Construction for Footings and Foundations
F-01206 IRIS One-Time Expense Request
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS)
F-47255 Emergency Medical Services Funding Assistance Program Municipal Signature and Population Verification Page
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge
F-00714 Business Associate Agreement - County or Tribal Contract
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-13072 Noncompound Drug Claim
F-00588a PPS AODA Deskcard
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA)
F-02208 Assisted Living Facility Self-Report
F-00367D Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 to 24Months
F-80962 New Capital Asset Record
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months


Last Revised: July 28, 2017