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 Language
F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening English
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa English
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request English
F-45032 License, Permit or Registration - Radiation Only English
F-00787 Prior Authorization - Requirement Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services English
F-00989K Transition Plan - Other (IFSP) English
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format English
F-44003 Lead-Safe Renovator Application English
F-00472 CSAS Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 English
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary English
F-05029 Request To Withdraw Voluntary Paternity Acknowledgement English
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC English
F-02111 Assisted Living – Fit and Qualified Application English
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services (PDF, 185 KB) English
F-80142 Collections Delegation Application English
F-01208 IRIS Consultant Agency Quality Management Plan English
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program English
F-00740 Quality Iimprovement Event Analysis Summary and Suggested Event Analysis Process English
F-00041 Asbestos Project Notification English
F-62320 Hospice Survey Information English
F-42014 Acuity Index (PDF, 656 KB) English
F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure (PDF, 171 KB) English
F-47208A Additional Page for Recreational Sanitation English
F-00913 Annual Survey of Nursing Homes English
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume English
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) English
F-44126 Antituberculosis Therapy Program Medication Refill Request (PDF, 40 KB) English
F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 English
F-00681C Family Care - Managed Care Organization (MCO) Two Options English
F-05260 Letter of Non-Marriage Application English
F-40036 Wisconsin Women, Infant, and Children (WIC) Program Vendor Agreement English
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases English
F-00309 Medicaid Provider Report English
F-80806 Purchase Requisition English
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment English
F-21076 Informed Consent - Children's Long-Term Support Functional Screen English
F-02034 Aging/ADRC Integration Funding Budget Worksheet English
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff English
F-62495 Compliance Statement English
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request (PDF, 154 KB) English
F-01788 Certification Regarding Debarment and Suspension English
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure (PDF, 178 KB) English
F-47461A Label-Wash English
F-00986 Newborn Screening Program - Condition Nomination English
F-01586 Medical Stockpile Access Request (PDF, 247 KB) English
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) English
F-44755 WIC Farmers' Market Nutrition Program English
F-00553 Professional & Occupational License Application & Affidavit English
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting English
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice English

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Last Revised: July 28, 2017