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-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-05046 Delayed Death - Court Order
F-01430 Prior Authorization Drug Attachment for Xyrem
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program
F-00334 Money Follows the Person (MFP) - Participant Reporting
F-01999A 2020 Retired Senior Volunteer Program: State Match Funding Application
F-01206B IRIS One-Time Expense Request - Ramp
F-80881 Profile ID Request (CARS)
F-21276A DCTS Coordinated Services Teams (CST) Grant / Contract Application Summary
F-00085 Power of Attorney for Health Care
F-62528 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Checklist
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-62287 Hospice Complaint Report
F-01020 Nursing Home Care Determination Request
F-11042 Prior Authorization Amendment Request
F-01634 Workplace Wellness Grant Program Application
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application
F-10096 Community Spouse Asset Share
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-42023 Vaccine Celsius Temperature Log
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice
F-82006 Employment Application and Resume
F-22540 Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs
F-00154 Wisconsin Consultative Examination Inquiry
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-62569 Individual Provider Status Approval Application and Supervisor Affidavit
F-16011 Quality Assurance (QA) Sample Checklist
F-01949A Tribal ADRS Annual Update
F-62441 Report of Hours Worked - Other Direct Care Nurse Aide / Evening
F-01068G General Pediatric Clinic - 15 Month Visit
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report
F-47128 Emergency Medical Technician - Basic Training Permit Application
F-00685 Statement of Tribal Affiliation
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information
F-00727 Typical Hearing Developmental Milestones
F-44000 Tuberculosis Disease Initial Request for Medication
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-82009V Confidential Information Release Authorization: Rehabilitation Review
F-01286 Template for Transition - Final Plan
F-01220 WISEWOMAN Healthy Lifestyle Assessment
F-22687 Collaborative Systems of Care (CSOC) Plan of Care
F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports
F-02210 Request for Dane County Support Broker to Attend Enrollment Counseling Session
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record
F-16034 Self-Employment Income Worksheet - Corporation


Last Revised: May 22, 2018