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 Language
F-80025 Forms / Publications Order English
F-01209 IRIS Certification Acknowledgment English
F-20822 County Review of Nursing Home, IMD or ICF/MR Referrals English
F-02011 Fluoride Mouthrinse Program Annual Report English
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail English
F-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers English
F-01726 Basic Equipment List for Nurse Aide Training Programs English
F-13146 Wisconsin Medicaid HIPAA Privacy Revocation of Authorization (PDF, 172 KB) English
F-47204 Hazard Summary Form English
F-00615 Change Project Report and Instructions English
F-01556D IRIS Program Letter – Disenrollment English
F-11033 Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) English
F-44063 Lead (Pb) Principal Instructor Application (PDF, 50 KB) English
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years (PDF, 28 KB) English
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) English
F-05281 Marriage Certificate Application - Wisconsin English
F-29323 Hardship Policy / Hidden Asset Policy (PDF, 17 KB) English
F-02217 Affidavit for Supplemental Nutrition Assistance Program – Puerto Rico English
F-00166 Service Delivery Discrimination Complaint English
F-80751 Non-County Resident Proceedings Cost Certification English
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment English
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution English
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ) English
F-62457 Request for Permission to Start Construction for Footings and Foundations English
F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit English
F-44161A WIC Cardholder Rights and Responsibilities English
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request (PDF, 183 KB) English
F-47255 Emergency Medical Services Funding Assistance Program Municipal Signature and Population Verification Page English
F-00681A Family Care - Three (3) Managed Care Organization (MCO) Options English
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup English
F-11055 STAT-PA System Instructions (PDF, 31 KB) English
F-44621 WIC Stock Price Survey English
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information English
F-01442 IRIS Disenrollment Letter - Death English
F-10108 Medicaid Manual Notice for Cost of Care Contribution English
F-40063 The Emergency Food Assistance Program (TEFAP) Commodities Complaint English
F-02271 Coordination of Confirmatory Testing Agreement English
F-00219 Self-Employment Income Report - Farmer English
F-80952A Contingency Plan - DHS Regional Offices English
F-01286 Template for Transition - Final Plan - Model English
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI English
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers English
F-00010 Risk Agreement - Participant English
F-62579 Post Survey Questionnaire English
F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification (PDF, 97 KB) English
F-16014 Notice of Program Violation (PDF, 43 KB) English
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program English
F-47471 Emergency Medical Technician Verification of Licensure English
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program English
F-01618 Client Services Agreement for Medicare Counseling English

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Last Revised: July 28, 2017