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-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-62024 Report of Hours Worked - Nurse Aide / Day
F-01750 Request for IMD Rebalancing Initiative Funding – Detail by Member
F-01646 AIDS/HIV Assistance and Insurance Assistance Program Insurance Enrollment Report (PDF, 193 KB)
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility
F-42010 Interjurisdictional Tuberculosis Notification
F-01352 Background Check Appeal Request - IRIS Program
F-01240 IRIS Critical Incident Reconciliation
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-01165 Newborn Report
F-00989N Other Services / Community and Medical Supports (IFSP)
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-62546 Corporate Guardianship Program Annual Report
F-01413 Post-Assessment Questionnaire
F-22018i HSRS Long-Term Support Module Desk Card
F-80882 CARS Contract Variance Correction
F-20810 Medicaid Waiver Program Health Report
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB)
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases
F-60947 Adult Day Care Initial Certification Checklist
F-62648A Personal Care Agency Sample Selection
F-01942A LTC FS - Diagnosis Verification Letter
F-62318 Hospice Quality Assessment and Performance Improvement Review
F-00193 Pediatric Referral / Communication Wisconsin WIC Program
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA)
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units)
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information
F-44016 Asbestos Occupant Protection Plan
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments
F-01319 IRIS Involuntary Disenrollment Request
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-00041 Asbestos Project Notification
F-01205P IRIS Participant Education: Background Check Process
F-01580 Noncompliance Roster
F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist)
F-10154 Statement of Identity for Children Under 18 Years of Age
F-44017 Asbestos Application - Individual
F-00309 Medicaid Provider Report
F-00164 Civil Rights Compliance Plan
F-00042 Knowledge Journal
F-01700 Exception-to-Policy Request (AIDS/HIV)
F-01596 Incident Report for CIP 1A/1B, CIP II, and COP-W Medicaid Waiver Programs
F-22491A Consumer Survey – OBVI
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-01321 Lyme Disease Case Report - Wisconsin
F-25392 Petition for Re-Examination


Last Revised: May 22, 2018