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 Division Other Location
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement DPH
F-00101 Authorization to Request Birth Records DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-62333 Plan Approval Application and Instructions DQA
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters DPH
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-45029 School Food Safety Program Inspection Report DPH
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-01601A CST Summary Line Item Budget DCTS
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-43009 Diabetes Emergency Action Plan DPH
F-00657 Nurse Aide Training Program: Military Training Verification DQA
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS
F-01240 IRIS Critical Incident Reconciliation DMS
F-22564 Authorization for Retroactive Caretaker Supplement (CTS) DMS
F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist DQA
F-80952 Contingency Plan - Health and Human Services Agencies DES
F-02191 CLTS County Waitlist Transition Plan DMS
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-62500 Health Care Facility Fire Report DQA
F-01744 Vaccine Restitution Policy - Agreement DPH
F-11076C Prior Authorization / Residential Care Center Treatment Attachment (PA/RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services DMS
F-47247 Ambulance Attendant License/Permit Renew DPH
F-01145 Wisconsin Hemophilia Home Care Program Residency Verification DMS
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-44013 Lead-Based Paint (LBP) Investigation Summary Report DPH
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS
F-01421 WISEWOMAN Monthly Reporting for Direct Services DPH
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-01278 Program Participation System (PPS) Employment Questions DMS
F-25392 Petition for Re-Examination DCTS
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 DQA
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities DQA
F-00615A Change Project Summary and Instructions DPH
F-00219 Self-Employment Income Report: Farm Business DMS
F-16033 FoodShare Worksheet DMS
F-62601 Rights of Home Health Agency Patients DQA
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-47479 Trauma Care Facility Classification Application DPH
F-01186 Wisconsin Chronic Renal Disease Program Application DMS
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra® DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-00915 Wisconsin Birth to 3 Program - Data Discussion Evaluation DMS
F-01558 Risk Agreement – IRIS Program DMS
F-02462 Tuberculosis (TB) Treatment Assistance Enrollment and Agreement DPH


Last Revised: March 26, 2019