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-00315 Written Prior Notice DMS
F-01261 Fraud Statement - IRIS Program DMS
F-00161 Caregiver Misconduct Reporting Requirements Worksheet DQA
F-01165 Newborn Report DMS
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day DQA
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-02432 IRIS Program HIPAA Breach and Unauthorized Disclosure Reporting DMS
F-11240 Case Management Provider Information OIG
F-01545 IRIS Fiscal Employer Agent (FEA) Biography DMS
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine DPH
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research DMS
F-00777 MAPT Vendor Related Allocation Formula DMS
F-02035 Aging/ADRC Integration Funding Request Application DPH
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-00375 Yellow Fever Uniform Stamp Application DPH
F-00262 Personal Care Agency Application Materials Checklist DQA
F-01210 IRIS Budget Amendment Request DMS
F-00098 Summary of Information Letter DMS
F-22018 HSRS Long-Term Support Module - Module Type A DMS
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster DMS
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-02538A CLTS Provider Cost-Based Outlier DMS
F-16031 Student Aid and Expense Worksheet DMS
F-01627 OARS Provider Case Manager Checklist DCTS
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-02466 MCO Appeal Log for Family Care, Family Care Partnership, and PACE Programs DMS
F-13072 Noncompound Drug Claim DMS
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume DMS
F-45022 Application for Material License DPH
F-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet DMS
F-01454E IRIS Program Withdrawal Letter – Voluntary DMS
F-02285 Pilot of Kindergarten Public Health Report, 2017-18 DPH
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet OS
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-00480 Child Outcomes Summary DMS
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DMS
F-01204C Letter - IRIS Program Notice of Action - Reduction DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-40335 Preschool Oral Health Preliminary Exam and Prevention Services DPH

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Last Revised: March 26, 2019