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-02031 Initial Application – Individual Lead Disciplines
F-62457 Request for Permission to Start Construction for Footings and Foundations
F-00913 Annual Survey of Nursing Homes
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter
F-12089 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request
F-47219 Agent Change Sheet
F-01604 Telehealth Application – Annual Review of Approval
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3)
F-44011 Application for Registration of Lead-Free or Lead-Safe Property
F-01459 Tuberculosis (TB) Program Dispensary Pre-Authorization for Non-Routine TB Services
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service
F-05029 Request To Withdraw Voluntary Paternity Acknowledgement
F-26100A Client Rights Limitation or Denial Documentation Review Schedule Supplement
F-02188 Lyme Disease Case Worksheet
F-82009II WIC Confidential Information Release Authorization
F-00054 Request for Waiver of Education / Experience Requirements (ADRC)
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet
F-02080 Dementia Crisis Innovation Grants: Round Two
F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination
F-01939 Wisconsin Medicaid Waiver Provider Registration
F-13149 HIPAA Privacy Accounting Request
F-47472 Emergency Medical Technician (EMT) License / First Responder Certification Renewal Application
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-00553 Professional & Occupational License Application & Affidavit
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA)
F-44161 WIC Rights and Responsibilities
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request
F-00335 Voluntary Agreement for Crisis Stabilization Services
F-05281 Wisconsin Marriage Certificate Application
F-40041 Certification and Food Package Pick-Up
F-00681CCCL Family Care - Managed Care Organization (MCO) Four Options (Large Print)
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral
F-00107 Self-Employment Income Report
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-21076 Informed Consent - Children's Long-Term Support Functional Screen
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications
F-62646 Home Health Agency (HHA) Patient Rights Statement Review
F-01016 ForwardHealth Provider Suggestion
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request
F-62022A Instructions for Report of Hours Worked and Resident Census Forms
F-00603a PPS Core Deskcard
F-01354 OARS Individual Service Plan (ISP)
F-11055 STAT-PA System Instructions
F-44763 Emergency Care - Do Not Resuscitate Order (DNR)
F-00989A Child and Family Information (IFSP)
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years


Last Revised: May 22, 2018