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 Language
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) English
F-00232 Notice of Action - MCOs English
F-44000 Tuberculosis Disease Initial Request for Medication (PDF, 4 MB) English
F-02068 Request to Establish a Children's COP Risk Reserve English
F-01204E Letter - IRIS Program Notice of Action--Functional Eligibility English
F-05032 Report of Birth Certificate Changes After Surrogate Birth English
F-00016 Wall Closure Inspection Checklist English
F-25614 Conditional Release Rules and Conditions English
F-01804 Appointment Results Wisconsin WIC Program English
F-80115 Operating Budget English
F-01209 IRIS Certification Acknowledgment English
F-20823 COP Functional Screen (PDF, 170 KB) English
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement (PDF, 115 KB) English
F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report English
F-62316 Hospice Patient Rights English
F-13146 Wisconsin Medicaid HIPAA Privacy Revocation of Authorization (PDF, 172 KB) English
F-00480 Child Outcomes Summary English
F-47205 Swimming Pool Inspection Report (PDF, 929 KB) English
F-01275A IRIS Provider Executive Staff Disclosure English
F-11033 Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) English
F-00264 Personal Care Agency Surveyor Guide English
F-44089 Wisconsin WIC Checks Accepted Here - Stickers English
F-62418 Adult Day Care Initial Certification Application English
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) English
F-05281 Marriage Certificate Application - Wisconsin English
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) English
F-40019 Affirmation of Identity, Residency, and/or Income English
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire English
F-80761 Contingent Account Activity Report English
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment English
F-21059 Variance Request for Institutional Respite English
F-01621 Smoking Cessation Data Collection English
F-00923 Reschedule Lead (PB) Certification Exam (PDF, 90 KB) English
F-62461 Application for Critical Access Hospital Certification of Approval English
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request (PDF, 183 KB) English
F-00538 CSAS Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 English
F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers English
F-11055 STAT-PA System Instructions (PDF, 31 KB) English
F-00315B Transition Written Prior Notice English
F-44702 Vaccine Administration Record English
F-02086 Histoplasmosis Case Worksheet English
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility English
F-10108 Medicaid Manual Notice for Cost of Care Contribution English
F-00079 Prior Authorization Drug Attachment for Modafinil and Nuvigil® English
F-40064 Transfer of The Emergency Food Assistance Program (TEFAP) Commodities between EFO's English
F-01949A Tribal ADRS Annual Update English
F-80962 New Capital Asset Record English
F-01286 Template for Transition - Final Plan - Model English
F-21276 DCTS Annual Grant/Contract Application English
F-01700 AIDS Drug Assistance Program (ADAP) Exception-to-Policy Request English


Last Revised: July 28, 2017