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-44151 Acute and Communicable Disease Case Report
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up
F-01430 Prior Authorization Drug Attachment for Xyrem®
F-10080 SeniorCare Authorization of Representative
F-40040 Envelope - Vendor and Integrity Unit #9
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-00166 Service Delivery or Employment Discrimination Complaint
F-80900 Receivables Annual Report
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-21076 Informed Consent - Children's Long-Term Support Functional Screen
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation
F-01068H General Pediatric Clinic - 18 Month Visit
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-47463B EMT - Basic Operational Plan Components
F-00688 Referral to Wisconsin Birth-3 Program
F-44192 Child Care Immunization Record
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services
F-44756 Wisconsin Tuberculosis Record Card
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-10114 Medicaid Disability Redetermination Report
F-40073 Monthly Physical Activity Sheet
F-02284 Record of School Employee Examination
F-00219 Self-Employment Income Report: Farm Business
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research
F-01302 Weekly Driver's Vehicle Inspection Report
F-21284 Clinician Confirmation of Diagnosis
F-20906 Alzheimer's Family and Caregiver Support Program Annual Fiscal Report
F-00010 Risk Agreement - Participant
F-62608 Request for Use of Medical Restraints
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements
F-16021 Student Financial Aid Report
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request
F-00842 Pharmacy Services Lock-In Program - Program Summary
F-01205M IRIS Participant Education: Restrictive Measures
F-11130 Federally Qualified Health Center Interim Report
F-45002C Restaurant/Retail Food Service Inspection Report Page 3
F-00478 Quality of Life Survey - Money Follows the Person (MFP)
F-00726 Typical Vision Developmental Milestones
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-00261 Personal Care Agency Personnel Record Review
F-01223 WISEWOMAN Case Management
F-01345 Special Care Environment Working Document
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-62671 Adult Family Home Initial Licensure Checklist
F-00043 Communication to Local Educational Agency Regarding Child Referral

Pages

Last Revised: July 28, 2017