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 Division Other Location
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-47463A First Responder Operational Plan Components DPH
F-01619 OARS Welcome Letter DCTS
F-00336 Tickborne Rickettsial Disease Case Report DPH
F-10112 Medicaid Disability Application DMS
F-44016 Asbestos Occupant Protection Plan DPH
F-01486 IRIS Consultant Biography DMS
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-29314 COP Declaration of Income and Assets, and State Residency DPH
F-01264 Service Fund Application for Reimbursement DPH
F-25527 Request for Increased Contract Allocation DCTS
F-01218 WISEWOMAN Client Consent DPH
F-02306 Application for Telecommunication Assistance Program (TAP) DPH
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-62611 Family Adult Day Care Certification Standards Checklist DQA
F-02026 Ethnicity and Race Selection DPH
F-00633 Notice and Consent for Screening DMS
F-11240 Case Management Provider Information OIG
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-01710 Home Health Agency Initial Licensure Checklist DQA
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years DMS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-44323 WIC Stock Price Survey – Pharmacy Only DPH
F-00989G Tell Us About Your Family (IFSP) DMS
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-01319 IRIS Involuntary Disenrollment Request DMS
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-00989-Packet Individualized Family Service Plan (IFSP) Packet DMS
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report DPH
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS
F-62674A Model Balance Sheet DQA
F-02068 Request to Establish a Children's COP Risk Reserve DMS
F-00754 Wisconsin Civil Service Request for Examination Accommodations DES
F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model DMS
F-62069 Home Health Agency Complaint Report DQA
F-01788 Certification Regarding Debarment and Suspension DES
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-10183 Information Change Report DMS
F-44815 Immunization Program Orders (Medical Authorization), Policy and Procedure Approval, and Indemnification DPH
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change DMS
F-00191 Certified Outpatient Clinic: Request for a Branch Office DQA
F-02109A CBRF – Established Provider Licensure Application DQA
F-05004 Birth Amendment - Affidavit DPH
F-40092 Physical Activity Zone DPH
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook DCTS
F-02377 Supported Decision-Making Agreement DPH

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Last Revised: March 26, 2019