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 Locationsort descending Language
F-00942 Meet Our "Henry" English
F-00653b Surgeon Data Import Training English
F-02107 Family Adult Day Care Center English
F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 English
F-02059 New Carrier Insurance Disclosure Onboarding (PDF, 750 KB) English
F-01766 TEFAP Shelter Review English
F-62274A Personal Care Agency Consent for Home Visit Spanish
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) English
F-47463E Emergency Medical Technician (EMT) - Paramedic Operational Plan Components (PDF, 27 KB) English
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment English
F-11183 Pharmacy Services Lock-In Program Member Referral to Another Provider for Services English
F-45022 Application for Material License English
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years (PDF, 28 KB) English
F-11023 Wisconsin Medicaid Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses and Cost Reports English
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification English
F-00262 Personal Care Agency Application Materials Checklist English
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information (PDF, 117 KB) English
F-01338 CLTS Parental Fee Declaration-Model English
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter English
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO English
F-01468A IRIS Program Start Date Letter – Transferring Participant English
F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results (PDF, 95 KB) English
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary English
F-81011 Cash Certification for Petty Cash, Canteen client / Resident and General Accounts English
F-22538 Consent to Film or Tape English
F-01210A IRIS Budget Amendment Provider Quote Comparison English
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program English
F-01149 Wisconsin Medicaid - Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements English
F-01063 HealthCheck Family History English
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist English
F-02118 Authorized Signer Designation for Access to PPS and FSIA English
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) English
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation English
F-01934 EMS First Responder Training Record - First Responder Refresher Requirements (PDF, 647 KB) English
F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers English
F-62092 Hospital Certificate of Approval Application English
F-13025 BadgerCare Plus Premium Employer Wage Withholding (PDF, 94 KB) English
F-11076B Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for continuing services English
F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) English
F-00588a PPS AODA Deskcard (PDF, 181 KB) English
F-10188 Undue Hardship Waiver Decision for Facility English
F-00221 Family Care / IRIS Member Requested Disenrollment English
F-00469 CSAS Medically Monitored Treatment Service Recertification Application - DHS 75.11 English
F-10096 Community Spouse Asset Share Notice English
F-01708 Case Management Comprehensive Assessment (PDF, 1 MB) English
F-01623 OARS - Residential Placement Reviews English
F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) English
F-00989J Transition Plan - Turning 3 Years Old (IFSP) English
F-00039 Asbestos Course Accreditation - Initial (PDF, 83 KB) English
F-44029 Credit Card Payment (PDF, 166 KB) English

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Last Revised: July 28, 2017