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-40108 Retail Vendor Application Amendment WIsconsin Women, Infant, and Children (WIC) Program
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters
F-01205F IRIS Participant Education: Complaints and Grievances
F-00014 Ceiling Closure Inspection Checklist
F-25904 Admission to Caseload - Revocation
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-00681EEE IRIS (Include, Respect, I Self-Direct) Four (4) Fiscal Employer Agent (FEA) Options
F-20445 Individual Service Plan - Medicaid Waivers
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-11304 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-01348 Determining the Weighted Care Management Rate-Direct Service Staff Worksheet
F-01016 ForwardHealth Provider Suggestion
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03
F-10108 Medicaid Manual Notice for Cost of Care Contribution
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-62595 Long-term Care Facility Feeding Assistant Roster
F-62224 Nurse Aide Training Program – Notice of Substantial Change
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments (PDF, 55 KB)
F-01204D Letter - IRIS Program Notice of Action - Termination
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-80962 New Capital Asset Record
F-62528 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Checklist
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA)
F-10146 Employer Verification of Earnings
F-01197 Certification of Need for Specialized Medical Vehicle Transportation
F-43026 Wisconsin Donor Registry User Access Request
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Providers
F-00479 Child Outcomes Fidelity Self-Assessment
F-22638 Notification of Waiver Program Termination
F-21059 Variance Request for Institutional Respite
F-00261 Personal Care Agency Personnel Record Review
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses
F-16038 Administrative Disqualification Hearing Notice
F-01601A CST Summary Line Item Budget
F-44000 Tuberculosis Disease Initial Request for Medication
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-00180B WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals - Self-Directed Supports
F-00480 Child Outcomes Summary
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA)
F-01931 Wisconsin EMS AEMT Training Record - AEMT Refresher Requirements
F-21063 Exception to Care Management / Support and Service Coordination Contact Requirements

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Last Revised: May 22, 2018