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-01545 IRIS Fiscal Employer Agent (FEA) Biography DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-02106 Adult Day Care Center – Applicant Compliance Statement DQA
F-00754 Wisconsin Civil Service Request for Examination Accommodations DES
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS
F-00537 Community Substance Abuse Services (CSAS) Intervention Services Initial Certification Application - DHS 75.16 DQA
F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment DPH
F-82018C Work Time Absence Record DES
F-10108 Medicaid Manual Notice for Cost of Care Contribution DMS
F-02047 IRIS Financial Reporting Template DMS
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-21276 DCTS Annual Grant/Contract Application DCTS
F-02558 Family Care Member Out-of-County Notification DMS
F-01209 IRIS Certification Acknowledgment DMS
F-01354 OARS Individual Service Plan (ISP) DCTS
F-00017 Blood Lead Lab Reporting DPH
F-16023 Striker Evaluation DMS
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-62022A Instructions for Report of Hours Worked and Resident Census Forms DQA
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume DMS
F-02413 BioSense Platform User Security and Confidentiality Agreement DPH
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-00943 Exhibit II - Tribal Work Plan OS
F-45022 Application for Material License DPH
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-02284 Record of School Employee Examination DPH
F-00633 Notice and Consent for Screening DMS
F-44126 Antituberculosis Therapy Program Medication Refill Request DPH
F-01204C Letter - IRIS Program Notice of Action - Reduction DMS
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding DMS
F-02122 Opioid Crisis State Targeted Response Program Funding Request DCTS
F-00476 CARES Automated Systems Access Request DMS
F-40117 Abortion Information Provision Certification DPH
F-80900A Receivables Quarterly Report DES
F-05281 Wisconsin Marriage Certificate Application DPH
F-01942A LTC FS - Diagnosis Verification Letter DMS
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey DQA
F-22688 Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide DCTS
F-62648A Personal Care Agency Sample Selection DQA
F-01805 Patient Rights for Victims of Sexual Assault, Human Trafficking Involving a Commercial Sex Act, or Child Sexual Abuse DQA
F-02494 ForwardHealth Prior Authorization Speech-Generating Device Skills and Needs Profile Attachment DMS
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS

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Last Revised: March 26, 2019