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-01293D Participant Fiscal Employer Agent (FEA) – Transfer Checklist DMS
F-62690 Feeding Assistant Competency Evaluation Skills Examination - Handwashing DQA
F-00036 Power of Attorney for Finance and Property DPH
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS
F-44757 WIC Farmer's Market Contract For Farmers DPH
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-02493 ForwardHealth Prior Authorization Speech-Generating Device Purchase Recommendation Attachment DMS
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-01016 ForwardHealth Provider Suggestion DMS
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-01321 Lyme Disease Case Report - Wisconsin DPH
F-02412 BioSense Platform Organization Security and Confidentiality Policy Agreement DPH
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-80477B Canteen Operations Balance Sheet - GAAP Basis DES
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-00334 Money Follows the Person (MFP) - Participant Reporting DMS
F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus OIG
F-62319 Hospice Volunteer Program Review DQA
F-01765 TEFAP Food Pantry Self-Assessment Tool DPH
F-02672 CLTS Waiver Sole Proprietor Registration DMS
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-45010D Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) DPH
F-01618 Client Services Agreement for Medicare Counseling DPH
F-02530 Application for Wisconsin's Test of English Proficiency (TEP) and Board for Examination of Interpreters (BEI) DPH
F-04003 Vendor Monitoring Worksheet: Wisconsin WIC Program DPH
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-40092 Physical Activity Zone DPH
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS
F-00633 Notice and Consent for Screening DMS
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request DCTS
F-80962 New Capital Asset Record DES
F-16066 FoodShare Wisconsin Income Change Report DMS
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years DMS
F-13039 Estate Recovery Program (ERP) Disclosure DMS
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-02011 Fluoride Mouth Rinse Program Annual Report DPH
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-45029 School Food Safety Program Inspection Report DPH
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report DPH
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa DMS
F-05032 Report of Birth Certificate Changes After Surrogate Birth DPH
F-01145 Wisconsin Hemophilia Home Care Program Residency Verification DMS
F-42016 Authorization for Release of Confidential HIV Test Results DPH
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS
F-29315 Declaration of Income and Assets, and State Residency Instructions DMS
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35 DQA

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Last Revised: March 26, 2019