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-01068L General Pediatric Clinic - Teenager Visit DMS
F-10080 SeniorCare Authorization of Representative DMS
F-44003 Lead-Safe Renovator Application DPH
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) DMS
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS
F-00685 Statement of Tribal Affiliation DMS
F-01210A IRIS Budget Amendment Provider Quote Comparison DMS
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) DPH
F-01413 Post-Assessment Questionnaire DPH
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-00380 Outpatient Mental Health Clinic Certification Withdrawal DQA
F-16014 Notice of Program Violation DMS
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report DQA
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application DQA
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) DPH
F-00974 Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor DPH
F-01162 Certification of Emergency for Non-U.S. Citizens DMS
F-10114 Medicaid Disability Redetermination Report DMS
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-01556D IRIS Program Letter – Disenrollment DMS
F-02109C CBRF – New Provider Licensure Application DQA
F-00855 Medication Therapy Management Case Management Software Requirements DMS
F-01264 Service Fund Application for Reimbursement DPH
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC DCTS
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook DCTS
F-02367 Non-Addictive, Non-Narcotic, Injectable Medication (NNAI) Medication Assisted Treatment (MAT) Service within the Jail Setting NNAI MAT Re-Entry Grant Application DCTS
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 DQA
F-16038 Administrative Disqualification Hearing Notice DMS
F-80122 Journal Voucher DES
F-02122 Opioid Crisis State Targeted Response Program Funding Request DCTS
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-11245 Family Planning Clinics or Agencies OIG
F-62231 Home Health Agency Personnel Record Review DQA
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-62697 Feeding Assistant Training Certification of Completion DQA
F-01197 Certification of Need for Specialized Medical Vehicle Transportation DMS
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding DMS
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01234 Explanation of Medical Benefits DMS
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-00926A Request for Use of Medical Restraints – CLTS DMS
F-01320 Lead Test Kit Documentation DPH
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-01428 Birth to 3 Program Invitation to Individualized Family Service Plan Meeting (IFSP) DMS
F-02426 DQA Misconduct Incident Reporting (MIR) System Account Registration Survey DQA
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 DQA
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS


Last Revised: March 26, 2019