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-62274A Personal Care Agency Consent for Home Visit Spanish
F-62569 Individual Provider Status Approval Application and Supervisor Affidavit English
F-01134 Wisconsin Medicaid - Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit English
F-16011 Quality Assurance (QA) Sample Check List (PDF, 226 KB) English
F-00568 EMS Board Sub-Committee Appointment Application English
F-47470 Change of EMS Medical Director English
F-11090 Mental Health Day Treatment Functional Assessment English
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services English
F-44817 Order To Cease Operation English
F02057 ADRC Authorization for the Release of Confidential Information English
F-01454B IRIS Program Withdrawal Letter – Health and Safety English
F-10137 Medicaid Change Report English
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement English
F-40104 WIC Retail Vendor Annual Food Sales Survey English
F-01942B LTC FS - Request Letter English
F-82069 Background Information Disclosure (BID) Appendix English
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS English
F-22433 Request for a Hearing, Wisconsin Birth to 3 Program English
F-00681DD IRIS (Include, Respect, I Self-Direct) Four Consultant Agency Options English
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease English
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record English
F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers English
F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) English
F-00628 Consortium Response to the State IM Second Party Review Finding English
F-60953 Adult Family Home Fire Safety Guide English
F-11260 Wisconsin Medicaid - Degree Addendum English
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up (PDF, 29 KB) English
F-45010D Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) English
F-02237 Pre-Hire Driving Record Review English
F-01481 Marriage Record Amendment Request Officiant Affidavit (PDF, 86 KB) English
F-10162 Verification of Veterans Benefits (PDF, 53 KB) English
F-00169 Opting Out of Local Educational Agency (LEA) Notification English
F-42017 Wisconsin Initial Refugee Health Assessment English
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist English
F-01227 WISEWOMAN Healthy Behavior Readiness Assessment Follow-Up English
F-04002 School Report to Local Health Department English
F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI) (PDF, 21 KB) English
F-01814 County Agency Children’s Community Options Program (CCOP) Five-Year Plan English
F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit English
F-62688 Feeding Assistant Training Program Trainer Application English
F-01201B IRIS Supportive Home Care / Self-Directed Personal Care / Respite Care Training Verification English
F-20415 CIP II Nursing Home Diversion Request Coversheet English
F-01588 Application for Available Beds English
F-00688 Referral to Wisconsin Birth-3 Program English
F-62155 Living Unit Census Report English
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request English
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets English
F-45025 Patient Questionnaire English
F-00989E Summary of Development - Child’s Independence and Ability to Meet Own Needs (IFSP) English
F-11008 Prior Authorization / Therapy Attachment (PA/TA) English

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Last Revised: July 28, 2017