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-01206 IRIS One-Time Expense Request
F-22550 Birth to 3 Program Parental Cost Share
F-00950 Notice of Denial of Medical Coverage – Partnership
F-20920 Formula to Determine Amount of Income Available to Pay for Room & Board in Substitute Care
F-02346 Training Course Accreditation Application Lead Disciplines
F-83263 Rehabilitation Review Application and Instructions
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request
F-80015 Summary of Depository Funds Annual Report
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing
F-11289 HealthCheck County Outreach Case Management Plan for County
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA)
F-00053 Notice of Intent to Submit an Application (ADRC)
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report
F-01997 Children's Community Options Reconciliation Packet
F-01821 WIC Authorized Infant Formula Supplier Application
F-47119 Ambulance Report
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP)
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant
F-42024 Vaccine Fahrenheit Temperature Log
F-01279 Program Participation System (PPS) Employment Interview
F-01200 IRIS Program Cost Share Repayment Agreement
F-01067 HealthCheck Your Child's Speech and Hearing
F-01275A IRIS Provider Executive Staff Disclosure
F-01454C IRIS Program Withdrawal Letter – No Contact
F-02412 BioSense Platform Organization Security and Confidentiality Policy Agreement
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-21343A Alzheimer's Family and Caregiver Support Program (AFCSP) Financial Eligibility Screen - Worksheets 1 and 2
F-80952A Contingency Plan - DHS Regional Offices
F-16039 Waiver of Administrative Disqualification Hearing
F-00907 Wisconsin Home Health Agency OASIS Assessment Deletion Request
F-13149 HIPAA Privacy Accounting Request
F-00596 PPS Mental Health Module
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10
F-00027 CSAS Standards Recertification Application - DHS 75.03
F-00330 Request for Replacement FoodShare Benefits
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-62657 Home Health Agency Contract Review Worksheet
F-02047 IRIS Financial Reporting Template
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire
F-11016 Prior Authorization Physician Attachment (PA/PA)
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators
F-10111 Good Faith Medicaid / BadgerCare Plus Certification

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Last Revised: May 22, 2018