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
F01454G IRIS Program Withdrawal Letter - Cancelled
F-62316 Hospice Patient Rights
F-11285 HealthCheck Screener Affirmation
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities
F-00681EEE IRIS (Include, Respect, I Self-Direct) Fiscal Employer Agent (FEA) Options
F-45023 Certificate - Use of Depleted Uranium under General License
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding
F-00004A Health and Employment Counseling - I Think I Need More Time
F-01571 Air Quality Measurement Device Maintenance and Calibration Log
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications
F-04002 School Report to Local Health Department
F-01430 Prior Authorization Drug Attachment for Xyrem®
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-22688 Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide
F-02258 Minority Health Advisory Committee Application
F-01199 Optional School-Based Services Activity Medication Administration
F-80900 Receivables Annual Report
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16
F-20445A Individual Service Plan - Individual Outcomes
F-02050 Coordinated Services Teams (CST) Final Expenditure Report
F-62461 Application for Critical Access Hospital Certification of Approval
F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-47236 Operations and Maintenance Certificate
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-00039 Asbestos Course Accreditation - Initial
F-01601A CST Summary Line Item Budget
F-44012 Lead Abatement Notification
F-05027B Report of Naturalization
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-00915 Wisconsin Birth to 3 Program - Data Discussion Evaluation
F-29314 COP Declaration of Income and Assets and State Residency
F-25615 Supervised Release Rules
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request
F-62588 Feeding Assistant Training Program Application
F-13148 HIPAA Privacy Access Request
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments
F-01931 Wisconsin EMS AEMT Training Record - AEMT Refresher Requirements
F-47477 First Responder / Emergency Medical Technician Certificate / License
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA)
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording
F-44236 Pertussis Case Report
F-05260 Letter of Non-Marriage Application
F-00726 Typical Vision Developmental Milestones

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Last Revised: May 22, 2018