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-00039 Asbestos Course Accreditation - Initial
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers
F-12029 Managed Care Disenrollment Request
F-43013 Diabetes Medical Management Plan
F-62500 Fire Report for Adult Family Homes, Community-Based Residential Facilities, FDDs, Hospitals, and Nursing Homes
F-01894 Vendor Overpayment Findings Letter
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-25180 Order of Discharge Upon Expiration of Commitment
F-00913 Annual Survey of Nursing Homes
F-01634 WorkPlace Wellness Grant Program Application
F-05027B Report of Naturalization
F-20572 Request for State Public Funding for Non-Residents
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06
F-01454B IRIS Program Withdrawal Letter – Health and Safety
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service
F-02329 VFC Change of Information
F-47247 Ambulance Attendant License/Permit Renew
F-82069 Background Information Disclosure (BID) Appendix Instructions for License Holders and Non Client Residents in DQA-Regulated Facilities
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
F-02074 Medicare Other Coverage Discrepancy Report
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request
F-44014 Lead-Free Inspection Affidavit of Property Owner
F-62601 Rights of Home Health Agency Patients
F-01934 Wisconsin EMS First Responder Training Record - First Responder Refresher Requirements
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA)
F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion
F-05260 Letter of Non-Marriage Application
F-20941A Informed Consent for Participation in Wisconsin Money Follows the Person Rebalancing Demonstration
F-00553 Professional & Occupational License Application & Affidavit
F-01481 Marriage Record Amendment Request Officiant Affidavit
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-00335 Voluntary Agreement for Crisis Stabilization Services
F-00681DDL IRIS (Include, Respect, I Self-Direct) Four Consultant Agency Options (Large Print)
F-47479 Trauma Care Facility Classification Application
F-01227 WISEWOMAN Healthy Behavior Support and Readiness Assessment
F-00113 Four Conditions for the Use of Funding in a CBRF
F-02118 Authorized Signer Designation for Access to PPS and FSIA
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request
F-44257 Wisconsin Immunization Record Card
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement
F-01016 ForwardHealth Provider Suggestion
F-62027 Report of Hours Worked - Registered Nurse / Night
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice

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Last Revised: May 22, 2018