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-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
F-00263 Personal Care Agency Record Review
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP)
F-05020A Paternity Order Due to Divorce - Custody
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification
F-02400A Client Transfer: Assisted Living Facility Capability
F-00040 Asbestos Course Accreditation - Renewal
F-00989-Packet Individualized Family Service Plan (IFSP) Packet
F-01199 Optional School-Based Services Activity Medication Administration
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals
F-02288 WisCaregiver Career Program: Registration Agreement
F-62692 Feeding Assistant Training Program Primary Instructor Application
F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model
F-02046 IRIS Financial Projections Template
F-13066 Claim Refund
F-62062 Hospice License Application
F-00543A File Review Checklist
F-01761 Intoxicated Driver Program Self-Evaluation
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2)
F-44819 Farmers Market Nutrition Program (FMNP) - Application for Farmstands
F-00315A Written Prior Notice - No Evaluation Recommended
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-05044 Cause of Death Amendment
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events
F-80190 Travel Reimbursement Request Non-State Employee
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request
F-62236 Hospice Clinical Record Review
F-00577 Report Fraud
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography
F-00366 Wisconsin Adult Long-Term Care Functional Screen
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application
F-42016 Authorization for Release of Confidential HIV Test Results
F-00119 Personal Care Agency Application for Approval
F-01427 Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting
F-01246 Background Information Disclosure Addendum—IRIS
F-22491 Consumer Report and Survey - OBVI
F-22538 Consent to Photograph or Record and Use of Photographs/Recordings
F-01999B 2020 Senior Companion Program: State Match Funding Application
F-80883 CARS Contract Adjustment - Extensions and Moves
F-01067 HealthCheck Your Child's Speech and Hearing

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Last Revised: May 22, 2018