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-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs
F-25904 Admission to Caseload - Revocation
F-21353 Children's Long-Term Support Waiver High-Cost Request
F-01415 IRIS Adult Family Home Taxable Income Information
F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports
F-05054 Court Order To Amend Cause of Death - 89
F-20009 Complaint Report
F-00565A County Performance Plan (CPP) Goals
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan
F-01207 IRIS Fiscal Employer Agent Quality Management Plan
F-02012 Fluoride Supplement Program Annual Report
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements
F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure
F-44444 WIC Vendor Supply Order
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA)
F-40058 Verification of Transfer of USDA Commodities
F-21059 Variance Request for Institution Respite
F-01219-pckt WISEWOMAN Assessment Packet
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips
F-10097 Medicaid Income Allocation Notice
F-20818 Certification for SSI-E Exceptional Expense Supplement
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-62657 Home Health Agency Contract Review Worksheet
F-00017 Blood Lead Lab Reporting
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-62030 Resident Census
F-01726 Basic Equipment List for Nurse Aide Training Programs
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request
F-16014 Notice of Program Violation
F-44815 Immunization Program Orders (Medical Authorization), Policy and Procedure Approval, and Indemnification
F-00989N Other Services / Community and Medical Supports (IFSP)
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds)
F-40096 eWIC Program Repayment Agreement
F-02467 Children's Long-Term Support: Care Level Classification
F-01208A IRIS Consultant Agency Quality Management Plan Tracking
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application
F-10126 Appoint, Change, or Remove an Authorized Representative
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement
F-80025 Forms / Publications Order
F-00049 Asbestos Principal Instructor Application
F-01287 Template for Transition - Initial Plan - Model


Last Revised: May 22, 2018