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 Division Other Locationsort descending
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster DMS
F-62652 Home Health Agency Licensure Survey Home Visit Guide DQA
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse DQA
F-62322 Hospice Inpatient Clinical Record Review DQA
F-02106D Adult Day Care Center – New Provider Certification Application Checklist DQA
F-01646 AIDS/HIV Assistance and Insurance Assistance Program Insurance Enrollment Report (PDF, 193 KB) DPH
F-47479 Trauma Care Facility Classification Application DPH
F-02400B Client Transfer: Labels DQA
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DMS
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit DMS
F-00989K Transition Plan - Other (IFSP) DMS
F-00014 Ceiling Closure Inspection Checklist DQA
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) DPH
F-01999B 2020 Senior Companion Program: State Match Funding Application DPH
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-00855 Medication Therapy Management Case Management Software Requirements DMS
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility DMS
F-44012 Lead Abatement Notification DPH
F-16066 FoodShare Wisconsin Income Change Report DMS
F-10162 Verification of Veterans Benefits DMS
F-00567 Emergency Medical Services Complaint DPH
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-05260 Letter of Non-Marriage Application DPH
F-22565 Authorization for Recoupment Caretaker Supplement DMS
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-02040 WIC Program Notice of Categorical Ineligibility DPH
F-00417 AODA Prevention Services Recertification Application - DHS 75.04 DQA
F-80464 Physical and Capital Inventory Compliance Certification DES
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-62594 Notice of Substantial Change Feeding Assistant Training Program DQA
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses DMS
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-62166 Report of Hours Worked - Licensed Practical Nurse / Night DQA
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-02432 IRIS Program HIPAA Breach and Unauthorized Disclosure Reporting DMS
F-11260 Degree Addendum OIG
F-00987E EMS Service Operational Plan Advanced Skills Addendum (Critical Care) DPH
F-44763 Emergency Care - Do Not Resuscitate Order (DNR) DPH
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-01546 IRIS Consultant Agency (ICA) Biography DMS
F-00703 Patient Side Training Report DPH
F-11136 Personal Care Addendum DMS

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Last Revised: March 26, 2019