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-62164 Report of Hours Worked - Licensed Practical Nurse / Day English
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program English
F-01668 Consent for Participation in Veterans Outreach and Recovery Program (VORP) English
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment English
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation English
F-01185 Wisconsin Adult Cystic Fibrosis Program Application English
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter English
F-01018 Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers English
F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure (PDF, 171 KB) English
F-60795 Community Based Residential Facility (CBRF) Fire Inspection English
F-01389B Mental Health Statistical Improvement Program (MHSIP) Family Satisfaction Survey English
F-11096 Prior Authorization / Care Plan Attachment English
F-45015 Application for Radioactive Material License for Broad Scope English
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services English
F-00262 Personal Care Agency Application Materials Checklist English
F-01204C Letter - IRIS Program Notice of Action - Reduction English
F-80952A Contingency Plan - DHS Regional Offices English
F-02208 Assisted Living Facility Self-Report English
F-00842 Pharmacy Services Lock-In Program - Program Summary English
F-62696 Student Nurse / Graduate Nurse Verification English
F-02118 Authorized Signer Designation for Access to PPS and FSIA English
F-00569 Request for Waiver of Administrative Rule for Licensure English
F-62470 Client / Patient / Resident Death Determination English
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) English
F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 English
F-00315B Transition Written Prior Notice English
F-29318 COP Financial Eligibility Determination Worksheet for Married Participants-Both on COP English
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) English
F-22018 HSRS Long-Term Support Module - Module Type A English
F-10161 Statement of Citizenship and/or Identity for Special Populations (PDF, 116 KB) English
F-62024 Report of Hours Worked - Nurse Aide / Day English
F-01937 Wisconsin EMS Paramedic Training Record - Paramedic Refresher Requirements English
F-42014 Acuity Index (PDF, 656 KB) English
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS English
F-01542 Notification of Required Drug Testing English
F-01208 IRIS Consultant Agency Quality Management Plan English
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses English
F-00989L Summary of Services (IFSP) English
F-16011 Quality Assurance (QA) Sample Check List (PDF, 226 KB) English
F-47463E Emergency Medical Technician (EMT) - Paramedic Operational Plan Components (PDF, 27 KB) English
F-00166 Service Delivery or Employment Discrimination Complaint English
F-11055 STAT-PA System Instructions (PDF, 31 KB) English
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions English
F-01145 Wisconsin Hemophilia Home Care Program Residency Verification English
F-01227 WISEWOMAN Healthy Behavior Support and Readiness Assessment English
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) English
F-80751 Non-County Resident Proceedings Cost Certification English
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility English
F-00688 Referral to Wisconsin Birth-3 Program English
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices English

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Last Revised: July 28, 2017