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
F-01788 Certification Regarding Debarment and Suspension
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume
F-43013 Diabetes Medical Management Plan
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement
F-01282 Monthly Enrollment Discrepancy Report Template - Model
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-01201A IRIS Participant - Hired Worker Relationship Identification
F-20946 Recertification Assurance--COP-W / CIP II
F-01068B General Pediatric Clinic - 6 to 8 Week Visit
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance
F-01389A MHSIP Youth Satisfaction Survey
F-00021 HealthCheck Referral
F-02208 Assisted Living Facility Self-Report
F-82003 Denial of Researcher Access To Health Care Records
F-02102 Getting Ready for the On-Site Visit - Birth to 3 Program
F-62688 Feeding Assistant Training Program Trainer Application
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator
F-62447 Misconduct Incident Report
F-13072 Noncompound Drug Claim
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application
F-11081 Rural Health Clinic Provider Staff Encounters
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36
F-10192 Medicaid Annuity Information - Disclosure
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB)
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-01936 Wisconsin EMS Intermediate Training Record - Intermediate Refresher Requirements
F-01708 Case Management Comprehensive Assessment
F-45023 Certificate - Use of Depleted Uranium under General License
F-01625 OARS Participant Discharge Summary
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice
F-04002 School Report to Local Health Department
F-29317 COP Initial Financial Eligibility Determination Worksheet for Married Applicants When One or Both Spouses Apply
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-01176 Prior Authorization Fax Cover Sheet
F-00989L Summary of Services (IFSP)
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-00681CL Family Care - Managed Care Organization (MCO) Two Options (Large Print)
F-01411 Education - Medication Summary - Part B
F-21365 Comprehensive Community Services Startup Outcomes - 2009
F-80857 Special CARS Run request
F-20810 Medicaid Waiver Program Health Report
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-00787 Prior Authorization - Requirement Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger

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Last Revised: May 22, 2018