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-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs DPH
F-16031 Student Aid and Expense Worksheet DMS
F-01894 Vendor Overpayment Findings Letter DMS
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail DQA
F-02536 Nursing Home: Waiver or Variance Request DQA
F-13066 Claim Refund DMS
F-01210B Budget Amendment Annual Verification (BAAV) Request DMS
F-00963 Children’s Long Term Support Reconciliation Packet DMS
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter DMS
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information DMS
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-42010 Interjurisdictional Tuberculosis Notification DPH
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-01229 WISEWOMAN Provider Assurances and Training Checklist DPH
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36 DQA
F-00334 Money Follows the Person (MFP) - Participant Reporting DMS
F-25393 Petition for Conditional Release DCTS
F-01332 Predispositional Investigation Report (PDI) DCTS
F-80477A Canteen Operations Analysis of Cash - GAAP Basis DES
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request DCTS
F-02012 Fluoride Supplement Program Annual Report DPH
F-00027 CSAS Standards Recertification Application - DHS 75.03 DMS
F-01201A IRIS Participant-Hired Worker Relationship Identification DMS
F-62588 Feeding Assistant Training Program Application DQA
F-02110C RCAC: New Provider Certification / Registration Application DQA
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) DMS
F-44161A WIC Cardholder Rights and Responsibilities DPH
F-01068B General Pediatric Clinic - 6 to 8 Week Visit DMS
F-62069 Home Health Agency Complaint Report DQA
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-00335 Voluntary Agreement for Crisis Stabilization Services DCTS
F-25527 Request for Increased Contract Allocation DCTS
F-80477B Canteen Operations Balance Sheet - GAAP Basis DES
F-00171 Lead Company Application DPH
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers DPH
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-01201C IRIS Participant Employer / Participant-Hired Worker Agreement DMS
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs DQA
F-02110D RCAC: New Provider Certification / Registration Application Checklist DQA
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-44212 School Report to the District Attorney DPH
F-01068C General Pediatric Clinic - 4 Month Visit DMS
F-62069A Personal Care Agency Complaint Report DQA
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-12022 Managed Care Program Provider Appeal DMS

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Last Revised: March 26, 2019