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-01618 Client Services Agreement for Medicare Counseling
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request
F-42002 Warning: Do Not Unplug Refrigerator - Label
F-01454C IRIS Program Withdrawal Letter – No Contact
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-22553A Free In-Service or Educational Training Request
F-00754 Wisconsin Civil Service Request for Examination Accommodations
F-83263 Rehabilitation Review Application and Instructions (PDF, 61 KB)
F-05027B Report of Naturalization
F-19002 Request to Reduce QUEST Card Balance
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08
F-02074 Medicare Other Coverage Discrepancy Report
F-62603 Adult Day Care and Family Adult Day Care Background Character Verification
F-01206B IRIS One-Time Expense Request - Ramp
F-00236 Request for a State Fair Hearing - MCO
F-01934 Wisconsin EMS First Responder Training Record - First Responder Refresher Requirements
F-45020 Cumulative Occupational Exposure History
F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey
F-00020 Drug Addition Review Request
F-01661 Letter – Foster Care Termination
F-13074 Pharmacy Special Handling Request
F-43013 Diabetes Medical Management Plan
F-01486 IRIS Consultant Biography
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA)
F-25180 Order of Discharge Upon Expiration of Commitment
F-00888 Next Steps
F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment
F-05260 Letter of Non-Marriage Application
F-20582 Medicaid – Katie Beckett Program Application and Recertification
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-02118 Authorized Signer Designation for Access to PPS and FSIA
F-62654 Home Health Agency Licensure Survey Exit Conference Guide
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review
F-47125 Emergency Medical Technician - Intermediate Training Permit Application
F-62030 Resident Census
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s)
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization
F-44014 Lead-Free Inspection Affidavit of Property Owner
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP)
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply
F-00943 Exhibit II - Tribal Work Plan
F-01204D Letter - IRIS Program Notice of Action - Termination
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-20942A Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13
F-02107 Family Adult Day Care Center


Last Revised: July 28, 2017