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 Language
F-62652 Home Health Agency Licensure Survey Home Visit Guide English
F-20415 CIP II Nursing Home Diversion Request Coversheet English
F-01009A Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under English
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure (PDF, 178 KB) English
F-00759 Business Associate Agreement - With Contract English
F-11271 Wisconsin Medicaid - Personal Care Provider Addendum English
F-00546 CSP for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 English
F-00390 Incident Report - Community Recovery Services (CRS) English
F-02080 Dementia Crisis Innovation Grants: Round Two English
F-02000 ADRC System User Access/Delete/Change English
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter English
F-01620 OARS Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services English
F-47029 Monthly Swimming Pool Operation Report (PDF, 86 KB) English
F-11035 Prior Authorization Dental Request English
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels* English
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF, 107 KB) English
F-43013 Diabetes Medical Management Plan (PDF, 587 KB) English
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards (Access to Toilet Facilities in Retail Establishments) (PDF, 36 KB) English
F-01310 IRIS Program Conflict of Interest Disclosure – Provider English
F-00164 Civil Rights Compliance Plan English
F-00042 Knowledge Journal English
F-01234 Explanation of Medical Benefits English
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program English
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) English
F-01406 Asthma Care - Release of Information English
F-22565 Authorization for Recoupment Caretaker Supplement English
F-80142 Collections Delegation Application English
F-01205E IRIS Participant Education: Program Integrity - Budget Monitoring English
F-21042 Medicaid Denial Chart English
F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey English
F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) English
F-00943 Exhibit II - Tribal Work Plan English
F-00653b Surgeon Data Import Training English
F-00516 CSAS Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 English
F-11134 Personal Care Prior Authorization Provider Acknowledgement English
F-02031 Initial Application – Individual Lead Disciplines English
F-62595 Long-term Care Facility Feeding Assistant Roster English
F-01763 TEFAP Review Findings for Food Pantries, Soup Kitchens and Shelters English
F-62231 Home Health Agency Personnel Record Review English
F-00681EEE IRIS (Include, Respect, I Self-Direct) Four (4) Fiscal Employer Agent (FEA) Options English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) English
F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model English
F-00657 Military Training Verification English
F-00517 CSAS Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 English
F-11136 Personal Care Addendum English
F-02050 Coordinated Services Teams (CST) Final Expenditure Report English
F-62601 Rights of Home Health Agency Patients English
F-01764 TEFAP Food Pantry Review English
F-62232 Hospice Contracts and Agreements Review English
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter English

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Last Revised: July 28, 2017