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-00161 Caregiver Misconduct Reporting Requirements Worksheet
F-01302 Weekly Driver's Vehicle Inspection Report
F-00714 Business Associate Agreement - County or Tribal Contract
F-00634B Records Access Log, Birth to 3 Program
F-00681B Partnership - Two (2) Managed Care Organization (MCO) Options
F-01407 Checklist (Astma Care and Environmental Strategies)
F-22564 Authorization for Retroactive Caretaker Supplement (CTS)
F-01205C IRIS Participant Education: One-Time Expense Requests
F-20987 Authorized Representative Designation, Medicaid Community Waiver Programs
F-01068J General Pediatric Clinic - Preschool Visit
F-16033 FoodShare Worksheet
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTSS
F-00646 Emergency Medical Service Training Center - Training Permit Eligibility Certification
F-02284 Record of School Employee Examination
F-11134 Personal Care Prior Authorization Provider Acknowledgement
F-80188 Check Distribution / Attachments
F-02031 Initial Application – Individual Lead Disciplines
F-62595 Long-term Care Facility Feeding Assistant Roster
F-01765 TEFAP Food Pantry Self-Assessment Tool
F-62231 Home Health Agency Personnel Record Review
F-13145 HIPAA Privacy Authorization for Use or Disclosure
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-11016 Prior Authorization Physician Attachment (PA/PA)
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months
F-10111 Good Faith Medicaid / BadgerCare Plus Certification
F-00236B Request for a State Fair Hearing - IRIS
F-00101 Authorization to Request Birth Records
F-44212 School Report to the District Attorney
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion
F-01275A IRIS Provider Executive Staff Disclosure
F-01454E IRIS Program Withdrawal Letter – Voluntary
F-00367D Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 to 24Months
F-00107 Self-Employment Income Report
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS)
F-00004A Health and Employment Counseling - I Think I Need More Time
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP)
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-01468 IRIS Program Start Date Letter – New Participant
F-42010 Interjurisdictional Tuberculosis Notification
F-29320 COP Cost-Share Worksheet #1 Instructions
F-01264 Service Fund Application for Reimbursement
F-22018i HSRS Long-Term Support Module Desk Card
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo
F-01062 HealthCheck Adolescent Review
F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents Renewal
F-82002 Denial of Government Access To Health Care Records (PDF, 13 KB)
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications

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Last Revised: July 28, 2017