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-47463B EMT - Basic Operational Plan Components
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07
F-44029 Credit Card Payment
F-01421 WISEWOMAN Monthly Reporting for Direct Services
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC
F-20985 Participant Rights and Responsibilities Notification
F-01407 Checklist (Astma Care and Environmental Strategies)
F-00004B Health and Employment Counseling - I Have Reached Employment
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation
F-02191 CLTS County Waitlist Transition Plan
F-62610 Nurse Aide Training Program Primary Instructor Application
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES)
F-00893 Affidavit of No Social Security Number - EMS Professional License
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request
F-01246 Background Information Disclosure Addendum—IRIS
F-01681 Comprehensive Community Services (CCS) Technical Assistance Survey
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions
F-22491AL Consumer Survey – OBVI (Large Print)
F-00272 WisTech Assistive Technology Advisory Council Member Application
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-40060 The Emergency Food Assistance Program Commodities Inventory Report
F-00607 Complaint Intake Survey
F-01410 Education - Medication Summary - Part A
F-00042 Knowledge Journal
F-11076A Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for Initial Admission and Unplanned Readmission within 90 Days of Discharge from RCC
F-20891 Intoxicated Driver Program Supplemental Funding Request
F-02257 Temperature Excursion Incident Report - Wisconsin Vaccines for Children Program (VFC)
F-62674 Home Health Agency License Application
F-10115 BadgerCare Plus / Medicaid Health Insurance Information
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-00950 Notice of Denial of Medical Coverage – Partnership
F-62069 Home Health Agency Complaint Report
F-01279 Program Participation System (PPS) Employment Interview
F-01708 Case Management Comprehensive Assessment
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05
F-44824 Wisconsin Day Care Assessment
F-45003 Occupational Exposure Record Per Monitoring Period
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP)
F-00315D Written Prior Notice - Additional Assessment Recommended
F-16033 FoodShare Worksheet
F-40104 WIC Retail Vendor Annual Food Sales Survey
F-02470 IRIS Noncompliance Statement and Corrective Action Plan
F-01389A MHSIP Youth Satisfaction Survey

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Last Revised: May 22, 2018