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-40073 Monthly Physical Activity Sheet
F-00219 Self-Employment Income Report: Farm Business
F-01406 Asthma Care (Release of Information )
F-01302 Weekly Driver's Vehicle Inspection Report
F-21284 Clinician Confirmation of Diagnosis
F-60945 Adult Family Home Initial Licensure Application
F-00010 Risk Agreement - Participant
F-62610 Nurse Aide Training Program Primary Instructor Application
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements
F-16021 Student Financial Aid Report
F-01937 Wisconsin EMS Paramedic Training Record - Paramedic Refresher Requirements
F-60309 Self-Supervision Evaluation and Waiver Request
F-00842 Pharmacy Services Lock-In Program - Program Summary
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections
F-11130 Federally Qualified Health Center Interim Report
F-45003 Occupational Exposure Record Per Monitoring Period
F-00478 Quality of Life Survey - Money Follows the Person (MFP)
F-01545 IRIS Fiscal Employer Agent (FEA) Biography
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-00261 Personal Care Agency Personnel Record Review
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records
F-01345 Special Care Environment Working Document
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request
F-00043 Communication to Local Educational Agency Regarding Child Referral
F-62674 Home Health Agency License Application
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement
F-16050 Agency Position on the State Quality Control (QC) Finding
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis
F-62069A Personal Care Agency Complaint Report
F-00917 Provider Enrollment Application Process
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra®
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators
F-00534 PACE / Partnership Member Requested Disenrollment
F-00989J Transition Plan - Turning 3 Years Old (IFSP)
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY)
F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation
F-01208A IRIS Consultant Agency Quality Management Plan Tracking
F-05020 Paternity Order Due to Divorce - Judgement
F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment
F-02110 Residential Care Apartment Complex (RCAC)
F-00060 Declaration to Physicians (Living Will)
F-80122 Journal Voucher
F-01205A IRIS Participant Education: Health and Safety - Incident Reporting
F-20448 Request for Medicaid Administrative Funds - Staff Position
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES)


Last Revised: July 28, 2017