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-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application DQA
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years DMS
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-80761 Annual Contingent Account Activity Report DES
F-02665 COVID-19: Assisted Living Change Worksheet DQA
F-02000 ADRC/Tribal ADRS/Aging System User: Access/Delete/Change DPH
F-21334 Encounter New User Request DMS
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS
F-02592 Rapid Test and Controls Inventory Log DPH
F-01749 Prior Authorization / Preferred Drug List (PA/PDL) for Hypoglycemics, Insulin – Long-Acting DMS
F-00236A Request for a State Fair Hearing - ADRC DPH
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-01210 IRIS Budget Amendment Request DMS
F-16026 Prosecution Diversion Agreement DMS
F-62233 Hospice Personnel Record Review DQA
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster DMS
F-01618 Client Services Agreement for Medicare Counseling DPH
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions DMS
F-00943 Exhibit II - Tribal Work Plan OS
F-47141 Emergency Medical Technician-Paramedic Training Permit Application DPH
F-00989B Summary of Development (IFSP) DMS
F-11054 Prior Authorization / Enteral Nutrition Formula Attachment (PA/ENFA) DMS
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports DMS
F-00603a PPS Core Deskcard DES
F-44444 WIC Vendor Supply Order DPH
F-01398 WISEWOMAN Client Home Blood Pressure Monitoring Agreement DPH
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-02191 CLTS County Waitlist Transition Plan DMS
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement DPH
F-01406 Asthma Care (Release of Information ) DPH
F-02059 New Carrier Insurance Disclosure Onboarding DMS
F21276C DCTS Annual Grant/Contract Application: Conde DCTS
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12 DQA
F-05291 Wisconsin Birth Certificate Application DPH
F-00330 Request for Replacement FoodShare Benefits DMS
F-25180 Order of Discharge Upon Expiration of Commitment DCTS
F-80122 Journal Voucher DES
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters DPH
F-00166 Service Delivery Discrimination Complaint DES
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals DCTS
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14 DQA
F-00332 Medicaid Purchase Plan Premium Information / Payment DMS
F-25206 Petition for Capias DCTS
F-80130 Financial Information  DES
F-01314 IRIS Program Employment Checklist DMS
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review DPH
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-62504 Behavioral Health Certification Section: Initial Certification Application DQA
F-02314E Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation for Annual Employee Screening DPH

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Last Revised: March 26, 2019