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-62274A Personal Care Agency Consent for Home Visit
F-00237SO Appeal Request - MCOs, Somali
F-02107 Family Adult Day Care Center
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-44757 WIC Farmer's Market Contract For Farmers
F-69306 General Observations of The Facility CMS-803
F-02011 Fluoride Mouthrinse Program Annual Report
F-00315D Written Prior Notice - Additional Assessment Recommended
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet
F-40073 Monthly Physical Activity Sheet
F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening
F-01726 Basic Equipment List for Nurse Aide Training Programs
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-01275 IRIS Provider Board Member Disclosure
F-21276A DCTS Coordinated Services Teams (CST) Grant / Contract Application Summary
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-16014 Notice of Program Violation
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under
F-01423 AIDS/HIV Drug Assistance and Insurance Assistance Program Market Place Enrollment Report
F-02217 Affidavit for Supplemental Nutrition Assistance Program – Puerto Rico
F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA)
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use)
F-80476 Asset Transfer
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-00367B Age-Specific ADL / IADL Answer Choices for Cildren's Long-Term Support Programs Age: 6 - 12 Months
F-10130 Medicaid Presumptive Disability
F-40310 Adult Oral Health Screening (PDF, 176 KB)
F-62320 Hospice Survey Information
F-44212 School Report to the District Attorney
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate
F-01319 IRIS Involuntary Disenrollment Request
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup
F-01162 Certification of Emergency for Non-U.S. Citizens
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA)
F-02288 WisCaregiver Career Program: Registration Agreement
F-00653a Patient Data Import Training
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification
F-45021 Generally Licensed Device Inspection by Mail
F-80921 Invoice Request (PRINT ON BUFF PAPER)
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers
F-00385 Nurse Aide Training - Student Waiver Request
F-10161 Statement of Citizenship and/or Identity
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine
F-62495 Compliance Statement
F-01894 Vendor Overpayment Findings Letter

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Last Revised: May 22, 2018