Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Locationsort descending
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-47463E Paramedic Operational Plan Components DPH
F-02638 Requesting PPS Access During COVID-19 Health Emergency DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-01710 Home Health Agency Initial Licensure Checklist DQA
F-02538A CLTS Provider Cost-Based Outlier DMS
F-00482 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Initial Certification Application - Chapter DHS 36 DQA
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-00334 Money Follows the Person (MFP) - Participant Reporting DMS
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program DPH
F-02466 MCO Appeal Log for Family Care, Family Care Partnership, and PACE Programs DMS
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-00166 Service Delivery Discrimination Complaint DES
F-22553A Free In-Service or Educational Training Request DPH
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-00020 Drug Addition Review Request DMS
F-01207 IRIS Fiscal Employer Agent Quality Management Plan DMS
F-01221 WISEWOMAN Screening Activity DPH
F-44243A Congenital Syphilis Case Investigation Report DPH
F-16076 FoodShare Six-Month Report and Instructions DMS
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-01068J General Pediatric Clinic - Preschool Visit DMS
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS
F-02059 New Carrier Insurance Disclosure Onboarding DMS
F-62166 Report of Hours Worked - Licensed Practical Nurse / Night DQA
F-02681 Community Engagement Assessment Tool Survey DPH
F-01804 Appointment Results Wisconsin WIC Program DPH
F-00923 Reschedule Lead (PB) Certification Exam DPH
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-45021 Generally Licensed Device Inspection by Mail DPH
F-01624 OARS Alternative to Revocation (ATR) Referral DCTS
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) DQA
F-02106D Adult Day Care Center – New Provider Certification Application Checklist DQA
F-00989N Other Services / Community and Medical Supports (IFSP) DMS
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS
F-02400A Client Transfer: Assisted Living Facility Capability DQA
F-01314 IRIS Program Employment Checklist DMS
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH
F-21334 Encounter New User Request DMS
F-80479 Audit Confirmation Request DES
F-02817 Annual Review for Division of Medicaid Services (DMS) Vendors DMS
F-02106 Adult Day Care Center – Applicant Compliance Statement DQA
F-02721B Notice of Medical Remedial Expenses DPH
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo DMS
F-16022 Social Security Number Referral DMS

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Last Revised: March 23, 2021