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-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility DCTS
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-62674A Model Balance Sheet DQA
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-01844 Wisconsin Notification of Death – Accounting of Estate Funds DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-62333 Plan Approval Application and Instructions DQA
F-02666 Prior Authorization Drug Attachment for Headache Agents, Acute Treatment DMS
F-00262 Personal Care Agency Application Materials Checklist DQA
F-11271 Personal Care Provider Addendum DMS
F-25205 Order to Transport DCTS
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00703 Patient Side Training Report DPH
F-47463E Paramedic Operational Plan Components DPH
F-02548 BadgerCare Plus Health Survey DMS
F-11022 Rural Health Clinic Statistical Data DMS
F-01626 OARS Facility Checklist DCTS
F-02108D Adult Family Home – New Provider Licensure Application Checklist DQA
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter DMS
F-02400B Client Transfer: Labels DQA
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 DQA
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs DMS
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-01442G IRIS Program Disenrollment Letter – Non-Spending DMS
F-22553A Free In-Service or Educational Training Request DPH
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers DMS
F-01212 Grievance - IRIS Program DMS
F-01221 WISEWOMAN Screening Activity DPH
F-02109 CBRF – Applicant Compliance Statement DQA
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS
F-02721A Notice of Delay in Functional Eligibility Determination DPH
F-13148 HIPAA Privacy Access Request DMS
F-02022 Claims Audit Report for Managed Long-Term Care MCOs DMS
F-00943 Exhibit II - Tribal Work Plan OS
F-62166 Report of Hours Worked - Licensed Practical Nurse / Night DQA
F-62645B Drug Repository Program: Donation Record DQA
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-01885 Requesting State Trauma Registry Access DPH
F-00043 Communication to Local Educational Agency Regarding Child Referral DMS
F-02583 Options Counseling Record Review Tool DPH
F-00603 PPS (Program Participation System) Core Module DES
F-45021 Generally Licensed Device Inspection by Mail DPH
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-01648 Coverdell Stroke Care Partner Agreement DPH
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-02108A Adult Family Home – Established Provider Licensure Application DQA
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP) DMS

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Last Revised: March 26, 2019