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 Division Other Location
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide DQA
F01454G IRIS Program Withdrawal Letter - Cancelled DMS
F-00479 Child Outcomes Fidelity Self-Assessment DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-47463A First Responder Operational Plan Components DPH
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-02547 Treatment Needs Question DMS
F-05210 Name Change Request Within 1st Year DPH
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC) DPH
F-22491A Consumer Survey – OBVI DPH
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-01206 IRIS One-Time Expense Request DMS
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP) DPH
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-25393A Petition for Supervised Release DCTS
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH
F-13393 Trading Partner 835 Designation DMS
F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits DQA
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding DMS
F-00538 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 DQA
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-01709 Case Management Service Plan DPH
F-00309 Medicaid Provider Report DQA
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DMS
F-44089 Wisconsin WIC Checks Accepted Here - Stickers DPH
F-00989P Individualized Family Service Plan Team Signature (IFSP) DMS
F-00041 Asbestos Project Notification DPH
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice DMS
F-25207 Order Granting Capias DCTS
F-01204E Letter – IRIS Program Notice of Action – Functional Eligibility DMS
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS
F-16028 Notice of FoodShare Overissuance DMS
F-69260 Resident Census and Conditions of Residents CMS-672 DQA
F-60945 Adult Family Home Initial Licensure Application DQA
F-00576A Tribal Aging and Disability Resource Specialist (TADRS) Annual Budget DPH
F-11129A Federally Qualified Health Center Cost Report Completion Instructions DMS
F-62069A Personal Care Agency Complaint Report DQA
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request DMS
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey DQA
F-62645B Drug Repository Program: Donation Record DQA
F-10137 Medicaid Change Report DMS
F-44727 WIC Vendor Training Proof DPH
F-01319C IRIS Program – Denial of Enrollment Letter DMS
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA

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Last Revised: March 26, 2019