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-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-80952A Contingency Plan - DHS Regional Offices
F-01205 IRIS Participant Education: Self-Direction Responsibilities
F-20582 Medicaid – Katie Beckett Program Application and Recertification
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding
F-62500 Fire Report for Adult Family Homes, Community-Based Residential Facilities, FDDs, Hospitals, and Nursing Homes
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced)
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter
F-13038 Notice of Intent to File a Lien
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments (PDF, 55 KB)
F-00567 Emergency Medical Services Complaint
F-01623 OARS - Residential Placement Reviews
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2)
F-44018 Request for Repairs
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB)
F-01454C IRIS Program Withdrawal Letter – No Contact
F-05044 Cause of Death Amendment
F-29319 COP Cost-Share Worksheet
F-02069 DHS Quarterly Report on Consumers Enrolled in CCS
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument
F-83263 Rehabilitation Review Application and Instructions
F-01210A IRIS Budget Amendment Provider Quote Comparison
F-20946 Recertification Assurance--COP-W / CIP II
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application
F-62601 Rights of Home Health Agency Patients
F-01020 Nursing Home Care Determination Request
F-01936 Wisconsin EMS Intermediate Training Record - Intermediate Refresher Requirements
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request
F-47489 EMS Patient Care Worksheet
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-44444 WIC Vendor Supply Order
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years
F-01486 IRIS Consultant Biography
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application
F-40058 Verification of Transfer of USDA Commodities
F-02008 CLTS Waivers Certification Exam
F-00164 Civil Rights Compliance Plan
F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment
F-01257 FoodShare Employment and Training (FSET) - Workshop Appointment
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers
F-02140 Urgent Services Agreement
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide
F-01068G General Pediatric Clinic - 15 Month Visit
F-01950 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-13509 Wisconsin Well Woman Program Provider Certification
F-62027 Report of Hours Worked - Registered Nurse / Night
F-00685 Statement of Tribal Affiliation

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Last Revised: May 22, 2018