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-01788 Certification Regarding Debarment and Suspension
F-11304 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-45032 License, Permit or Registration - Radiation Only
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
F-00714 Business Associate Agreement - County or Tribal Contract
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents
F-01442 IRIS Disenrollment Letter - Death
F-04020L Student Immunization Record, Long
F-25206 Petition for Capias
F-02306 Application for Telecommunication Assistance Program (TAP)
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget
F-80952A Contingency Plan - DHS Regional Offices
F-01201A IRIS Participant - Hired Worker Relationship Identification
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request
F-44019A Immunization Assessment
F-62500 Fire Report for Adult Family Homes, Community-Based Residential Facilities, FDDs, Hospitals, and Nursing Homes
F-00963 Children’s Long Term Support Reconciliation Packet
F-01899 Central Line-Associated Bloodstream Infection (CLABSI)
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions
F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-01623 OARS - Residential Placement Reviews
F-11016 Prior Authorization Physician Attachment (PA/PA)
F-44017 Asbestos Application - Individual
F-00330 Request for Replacement FoodShare Benefits
F-01454C IRIS Program Withdrawal Letter – No Contact
F-05033 Birth Amendment - Baptismal
F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP
F-02341A Wisconsin Children's Long-Term Support (CLTS) Waiver Provider Registration
F-00098 Summary of Information Letter
F-83263 Rehabilitation Review Application and Instructions
F-01206B IRIS One-Time Expense Request - Ramp
F-20941 Informed Consent for Participation in Wisconsin's Money Follows the Person (MFP) Demonstration
F-60945 Adult Family Home Initial Licensure Application
F-62601 Rights of Home Health Agency Patients
F-01012 Reimbursement Request for a PASRR Level I Screen
F-01937 Wisconsin EMS Paramedic Training Record - Paramedic Refresher Requirements
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint
F-47484 Pre-Review Questionnaire and Application Checklist
F-00596a PPS Mental Health Deskcard
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections
F-11035 Prior Authorization Dental Request Form (PA/DRF)
F-44323 WIC Stock Price Survey – Pharmacy Only
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months
F-01486 IRIS Consultant Biography
F-05291 Wisconsin Birth Certificate Application
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application


Last Revised: May 22, 2018