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-01649 Coverdell Stroke Champion Partner Agreement
F-11027 Rural Health Clinic Quarterly Cost Report
F-44126 Antituberculosis Therapy Program Medication Refill Request
F-00366 Wisconsin Adult Long-Term Care Functional Screen
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bedhold Days
F-05098 Court Order to Correct Facts, Misrepresented Information
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing
F-00681AL Family Care – Three (3) Managed Care Organization (MCO) Options (Large Print)
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-01219 WISEWOMAN Health History Assessment
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home / Institution
F-62671 Adult Family Home (AFH) Initial Licensure Checklist
F-62643 Drug Repository Program Notice of Participation or Withdrawal
F-01062 HealthCheck Adolescent Review
F-25205 Order to Transport
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist
F-00639 Agency Data Security Staff User Agreement
F-01627 OARS Provider Case Manager Checklist
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21
F-44755 WIC Farmers' Market Nutrition Program
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification
F-22491A Consumer Survey – OBVI
F-10098 Medicaid Member Asset Allocation Notice
F-40071 Children's Physical Activity Chart
F-02369 Certification of Need for Laboratory Services
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification
F-01412 Pre-Assessment Questionnaire
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-62687 Nurse Aide Training Program Trainer Application
F-01068K General Pediatric Clinic - Elementary School Visit
F-16006 FoodShare Wisconsin Change Report
F-01997 Children's Community Options Reconciliation Packet
F-62096A DQA Authority for Obtaining Provider Records Without Written Release
F-00704 Prior Authorization - Committee Public Testimony Registration
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program
F-11081 Rural Health Clinic Provider Staff Encounters
F-45008 Application for Radioactive Material License for Medical Use
F-00458 TDAP Cocooning Report
F-00989P Individualized Family Service Plan Team Signature (IFSP)
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB)
F-21581A Wisconsin Children’s Long-Term Support (CLTS) Waiver Program Family Outcomes Survey
F-00221A Family Care / Partnership / PACE / IRIS Change Routing and Instructions
F-01389B MHSIP Family Satisfaction Survey
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook
F-01314 IRIS Program Employment Checklist

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Last Revised: May 22, 2018