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 Language
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation English
F-02066 Abbreviated Denial Corrective Action Plan (CAP) Wisconsin WIC Program English
F-01204C Letter - IRIS Program Notice of Action--Reduction English
F-05027B Report of Naturalization English
F-00014 Ceiling Closure Inspection Checklist English
F-25393 Petition for Conditional Release English
F-00192 Referral / Communication Wisconsin WIC Program English
F-80015 Summary of Depository Funds Annual Report English
F-01207 IRIS Fiscal Employer Agent Quality Management Plan English
F-20818 Certification for SSI-E Exceptional Expense Supplement English
F-01644 Parents Who Host, Lose The Most Application English
F-00842 Pharmacy Services Lock-In Program - Program Summary (PDF, 47 KB) English
F-62296 Entrance Conference Checklist English
F-13074 Pharmacy Special Handling Request English
F-00478 Quality of Life Survey - Money Follows the Person (MFP) English
F-47198 Noise Exposure Sampling Sheet English
F-01556C IRIS Program Cost Share Letter – Repayment Plan English
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) English
F-00262A Personal Care Agency Application Regulatory Guidance Checklist English
F-44029 Credit Card Payment (PDF, 166 KB) English
F-62381 Residential Care Apartment Complex Regulations Compliance Statement English
F-01361 ForwardHealth Provider Express Enrollment Change of Address English
F-05218 E-mail Notification Request For New Publication Release English
F-00046 Family Care Program - Enrollment English
F-29322 Uniform Cost Sharing Plan - COP Cost-Share Worksheet 3 English
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline English
F-80479 Audit Confirmation Request English
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice English
F-21055 Home Modification Request for a Ramp English
F-01210B Budget Amendment Annual Verification (BAAV) Request English
F-00917 Provider Enrollment Application Process English
F-62447 Misconduct Incident Report English
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization (PDF, 163 KB) English
F-00534 PACE / Partnership Member Requested Disenrollment English
F-47247 Ambulance Attendant License/Permit Renew English
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) English
F-00315 Written Prior Notice - Birth to 3 English
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions English
F-00681DR IRIS (Include, Respect, I Self-Direct) Two Consultant Agency Options-Regional English
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) English
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice English
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization English
F-40062 The Emergency Food Assistance Program TEFAP and CSFP Commodity Loss Report English
F-01952 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Giant Cell Arteritis, and Neonatal Onset Multisystem Inflammatory Disease (NOMID) English
F-80952 Contingency Plan - Health and Human Services Agencies English
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting English
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard (PDF, 43 KB) English
F-01682 Wisconsin State Certified Peer Specialist Trainer Application English
F-00987C EMS Service Operational Plan Advanced Skills Addendum – First Responder English
F-00987D EMS Service Operational Plan Advanced Skills Addendum – Paramedic English

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Last Revised: July 28, 2017