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-47097 Application for Registration of X-Ray Devices
F-00905 Tuberculosis Disease - Initial Medication Request
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication
F-02257 Temperature Excursion Incident Report - WIsconsin Vaccines for Children Program (VFC)
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation
F-80882 CARS Contract Variance Correction
F-05020A Paternity Order Due to Divorce - Custody
F-01989 Renewal Application – Individual Lead Disciplines
F-00316 Child Enrollment Status Regarding Birth to 3 Program
F-25392 Petition for Re-Examination
F-62447 Misconduct Incident Report
F-01204 Notice of Action—IRIS Program
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request
F-00085 Power of Attorney for Health Care
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-01601 DCTS Summary Line Item Budget
F-13038 Notice of Intent to File a Lien
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older
F-47463A First Responder Operational Plan Components
F-00986A Newborn Screening Program Conflict of Interest Disclosure
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2)
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program
F-00588 PPS Alcohol and Other Drug Abuse Module
F-44029 Credit Card Payment
F-82009 Confidential Information Release Authorization - Generic 
F-05044 Cause of Death Amendment
F-83271 DHS Website Feedback
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months
F-29321 COP Cost-Share Worksheet #2
F-62579 Post Survey Questionnaire
F-01210 IRIS Budget Amendment Request
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request
F-20980 Assessment / Supplement to the Long Term Care Functional Screen
F-01655 Enrollment Discrepancy Report
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age)
F-49357 Personal Diabetes Care Record
F-00237SO Appeal Request - MCOs, Somali
F-62274A Personal Care Agency Consent for Home Visit

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Last Revised: May 22, 2018