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-02112 2017 Community Support Program (CSP) Survey Worksheet
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs
F-80976 Employment and Education History Summary
F-01205 IRIS Participant Education: Self-Direction Responsibilities
F-20810 Medicaid Waiver Program Health Report
F-01844 Wisconsin Notification of Death – Accounting of Estate Funds
F-00052B Cares Data Access and Use Agreement / Designation of Cares Security and Data Exchange Coordinator
F-62504 Community Substance Abuse Services (CSAS) or Mental Health Clinic Initial Certification Application
F-00192 Referral / Communication Wisconsin WIC Program
F-13039 Estate Recovery Program (ERP) Disclosure
F-47463B EMT - Basic Operational Plan Components
F-00963 Children’s Long Term Support Reconciliation Packet
F-01644 Parents Who Host, Lose The Most Application
F-11022 Rural Health Clinic Statistical Data
F-44063 Lead (Pb) Principal Instructor Application
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-01468 IRIS Program Start Date Letter – New Participant
F-05044C Coroner / Medical Examiner - Cause of Death Amendment
F-29322 Uniform Cost Sharing Plan - COP Cost-Share Worksheet 3
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-01406 Asthma Care (Release of Information )
F-01210A IRIS Budget Amendment Provider Quote Comparison
F-20985 Participant Rights and Responsibilities Notification
F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application
F-00100 State Vital Records Birth Certificate Request Letter
F-62608 Request for Use of Medical Restraints
F-01930 Minority Health Advisory Group Nomination and Agreement
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request
F-01012 Reimbursement Request for a PASRR Level I Screen
F-01210B Budget Amendment Annual Verification (BAAV) Request
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA)
F-44621 WIC Stock Price Survey
F-00596a PPS Mental Health Deskcard
F-01545 IRIS Fiscal Employer Agent (FEA) Biography
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice
F-40062 TEFAP / CSFP Commodity Loss Report
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-21225 Program Participation System (PPS): B-3 Module
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
F-01949 ADRC Annual Update
F-01949A Tribal ADRS Annual Update
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-62069 Home Health Agency Complaint Report


Last Revised: May 22, 2018