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-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced)
F-01246 Background Information Disclosure Addendum—IRIS
F-40071 Children's Physical Activity Chart
F-02282A Resident Relocation Plan
F-01413 Post-Assessment Questionnaire
F-00567 Emergency Medical Services Complaint
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-11136 Personal Care Addendum
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request
F-62688 Feeding Assistant Training Program Trainer Application
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey
F-02287 Vaccine Return - Request for Authorization to Return
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-62096A DQA Authority for Obtaining Provider Records Without Written Release
F-00114 EMS Service Director License Proxy for Individuals
F-01593A Civil Money Penality (CMP) Funded Project Report
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-45008 Application for Radioactive Material License for Medical Use
F-00989 Individualized Family Service Plan (IFSP)
F-01020 Nursing Home Care Determination Request
F-01279 Program Participation System (PPS) Employment Interview
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB)
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable
F-22491 Consumer Report and Survey - OBVI
F-02210 Request for Dane County Support Broker to Attend Enrollment Counseling Session
F-80188 Check Distribution / Attachments
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years
F-16033 FoodShare Worksheet
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA)
F-62288 Care Level Determination Worksheet
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-00681DDD IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application
F-45019 Reciprocity Privileges Checklist
F-01319C IRIS Program – Denial of Enrollment Letter
F-01068G General Pediatric Clinic - 15 Month Visit
F-01332 Predispositional Investigation Report (PDI)
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment
F-01321 Lyme Disease Case Report - Wisconsin
F-00685 Statement of Tribal Affiliation
F-01165 Newborn Report
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA)
F-00615A Change Project Summary and Instructions
F-80881 Profile ID Request (CARS)
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information
F-20415 CIP II Nursing Home Diversion Request Coversheet
F-01989 Renewal Application – Individual Lead Disciplines

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Last Revised: May 22, 2018