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-00039 Asbestos Course Accreditation - Initial
F-01580 Noncompliance Roster
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-44002 Asbestos Certification Application - Company
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-00913 Annual Survey of Nursing Homes
F-05027B Report of Naturalization
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC
F-02112 2017 Community Support Program (CSP) Survey Worksheet
F-81011 Cash Certification for Petty Cash, Canteen client / Resident and General Accounts
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-20823 COP Functional Screen
F-02066 Abbreviated Denial Corrective Action Plan (CAP) Wisconsin WIC Program
F-62537 Petition for Building Code Variance
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service
F-00193 Pediatric Referral / Communication Wisconsin WIC Program
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request
F-47463E Paramedic Operational Plan Components
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO
F-01646 AIDS/HIV Assistance and Insurance Assistance Program Insurance Enrollment Report (PDF, 193 KB)
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA)
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination
F-05260 Letter of Non-Marriage Application
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report
F-01408 Asthma Control Summary
F-00553 Professional & Occupational License Application & Affidavit
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-21059 Variance Request for Institutional Respite
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement
F-62641 Hospice Inpatient Symptom Management and Respite Contract or Agreement Review
F-00335 Voluntary Agreement for Crisis Stabilization Services
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request
F-60795 Community Based Residential Facility (CBRF) Fire Inspection
F-00113 Four Conditions for the Use of Funding in a CBRF
F-01210B Budget Amendment Annual Verification (BAAV) Request
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-44746 Farmers Market Nutrition Program (FMNP) - Site Observation Worksheet
F-01549 IRIS Certification Designation of Confidential and Proprietary Information
F-01016 ForwardHealth Provider Suggestion
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-40071 Children's Physical Activity Chart
F-01409 Client Information Intake
F-00603a PPS Core Deskcard
F-01282 Monthly Enrollment Discrepancy Report Template - Model
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet


Last Revised: May 22, 2018