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-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request DMS
F-62369 Waiver of Hospice or Home Health Services by a Terminally Ill Resident of a Community Based Residential Facility (CBRF) DQA
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review DPH
F-11042 Prior Authorization Amendment Request DMS
F-45029i Instructions For School Food Safety Plan DPH
F-01068F General Pediatric Clinic - 12 Month Visit DMS
F-01601B ISP Line Item Detail Budget DCTS
F-10096 Community Spouse Asset Share DMS
F-43013 Diabetes Medical Management Plan DPH
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program DMS
F-01246 Background Information Disclosure Addendum—IRIS DMS
F-22565 Authorization for Recoupment Caretaker Supplement DMS
F-00385 Nurse Aide Training - Student Waiver Request DQA
F-80952A Contingency Plan - DHS Regional Offices DES
F-44160A WIC Plastic Cover for WIC ID Folder (order in multiples of 200) DPH
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-16011 Quality Assurance (QA) Sample Checklist DMS
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-02000 ADRC/Aging System User: Access/Delete/Change DPH
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-47255 Emergency Medical Services Funding Assistance Program Municipal Signature and Population Verification Page DPH
F-01146 Wisconsin Chronic Disease Program Provider Data Sheet DMS
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP) DPH
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS
F-44014 Lead-Free Inspection Affidavit of Property Owner DPH
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet DQA
F-01279 Program Participation System (PPS) Employment Interview DMS
F-25393 Petition for Conditional Release DCTS
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08 DQA
F-83263 Rehabilitation Review Application and Instructions OS
F-02258 Minority Health Advisory Committee Application DPH
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-62603 Adult Day Care and Family Adult Day Care Background Character Verification DQA
F01454G IRIS Program Withdrawal Letter - Cancelled DMS
F-11240 Case Management Provider Information OIG
F-47482 EMT Training Center Certification Application DPH
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-10150A Your Rights and Responsibilities for Health Care DMS
F-44257 Wisconsin Immunization Record Card DPH
F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance DMS
F-00989A Child and Family Information (IFSP) DMS
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-01338 Children's Long-Term Support Parental Fee Declaration - Model DMS
F-40054 Confidential Birth Defects Registry Report DPH
F-00515 Community Substance Abuse Services (CSAS) Day Treatment Service Initial Certification Application - DHS 75.12 DQA


Last Revised: March 26, 2019