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-04020L Student Immunization Record, Long
F-00017 Blood Lead Lab Reporting
F-01409 Client Information Intake
F-25904 Admission to Caseload - Revocation
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding
F-01201C IRIS Participant Employer / Participant-Hired Worker Agreement
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist
F-62680 Home Health Agency Clinical Record Review
F-20823 COP Functional Screen
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions
F-00513 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Initial Certification Application - DHS 75.14
F-62092 Hospital Certificate of Approval Application
F-47463D Intermediate Operational Plan Components
F-11016 Prior Authorization Physician Attachment (PA/PA)
F-00272 WisTech Assistive Technology Advisory Council Member Application
F-00989M Justification for Services Provided in Locations Other than Natural Environments (IFSP)
F-44118 WIC Vendor Application
F-02339 Disaster Response Interpreter (DRI) Deployment Checklist for Community Shelters and Media Events
F-05033 Birth Amendment - Baptismal
F-00049 Asbestos Principal Instructor Application
F-01389 ROSI Adult Satisfaction Survey
F-40028 Participant Determination Letter
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application
F-01208 IRIS Consultant Agency Quality Management Plan
F-00942 Meet Our "Henry"
F-80130 Financial Information 
F-21059 Variance Request for Institutional Respite
F-01936 Wisconsin EMS Intermediate Training Record - Intermediate Refresher Requirements
F-13150 HIPAA Privacy Alternate Communication Request
F-00543A File Review Checklist
F-62281 Care Level Change Notice
F-60367 Community Advisory Committee Documentation
F-11035 Prior Authorization Dental Request Form (PA/DRF)
F-00315C Prior Notice and Consent for Evaluation and Assessment
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-44727 WIC Vendor Training Proof
F-62546 Corporate Guardianship Program Annual Report
F-05291 Wisconsin Birth Certificate Application
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-44771AA Medicaid Targeted Case Management Face Sheet - Childhood Lead Poisoning
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report
F-02140 Urgent Services Agreement
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election
F-80783A Family Financial Questionnaire - County Use
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-21276 DCTS Annual Grant/Contract Application
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization


Last Revised: May 22, 2018