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-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA)
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness
F-05021T Report of Legal Name Change - Tribal
F-25207 Order Granting Capias
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-80921 Invoice Request (PRINT ON BUFF PAPER)
F-00596 PPS Mental Health Module
F-01205D IRIS Participant Education: Program Integrity - Fraud Prevention
F-20810 Medicaid Waiver Program Health Report
F-02052 Asbestos Abatement Project Log
F-62496 Free-Standing Community-Based Residential Facility (CBRF) Plan Approval Application
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program
F-13066 Claim Refund
F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum
F-01618 Client Services Agreement for Medicare Counseling
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs
F-44017 Asbestos Application - Individual
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-01068A General Pediatric Clinic - 3 to 4 Week Visit
F-05046 Delayed Death - Court Order
F-29319 COP Cost-Share Worksheet
F-02331 Caregiver Programs Customer Satisfaction Survey
F-82064 Background Information Disclosure (BID)
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36
F-20980 Assessment / Supplement to the Long Term Care Functional Screen
F-02053 ADRC Referral to Income Maintenance
F-62595 Long-term Care Facility Feeding Assistant Roster
F-00390 Incident Report - Community Recovery Services (CRS)
F-01933 WIsconsin EMS EMT Training Record - NCCP EMT Refresher Requirements
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request
F-47484 Pre-Review Questionnaire and Application Checklist
F-00191A Certified Outpatient Clinic Request for a School Branch Office
F-01661 Letter – Foster Care Termination
F-11042 Prior Authorization Amendment Request
F-44323 WIC Stock Price Survey – Pharmacy Only
F-01319B IRIS Denial of Enrollment Request
F-10096 Community Spouse Asset Share
F-40058 Verification of Transfer of USDA Commodities
F-00681DL IRIS (Include, Respect, I Self-Direct) Two Consultant Agency Options (Large Print)
F-01226 WISEWOMAN Lifestyle Program Follow-Up
F-00780 Options Counseling Tip Card
F-01267 Aging and Disability Resource Center (ADRC) Complaint Report
F-21150A Adult Protective Services (APS) Investigation Transfer - Model
F-02102 Getting Ready for the On-Site Visit - Birth to 3 Program
F-62652A Personal Care Agency Home Visit Guide


Last Revised: May 22, 2018