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-02112 2017 Community Support Program (CSP) Survey Worksheet
F-01406 Asthma Care (Release of Information )
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-80130 Financial Information 
F-01989 Renewal Application – Individual Lead Disciplines
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs
F-16025 Disqualification Consent Agreement
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records
F-62166 Report of Hours Worked - Licensed Practical Nurse / Night
F-13033 Probate Claims Notice
F-00615 Change Project Report and Instructions
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds)
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application
F-00476 CARES Automated Systems Access Request
F-10191 Medicaid Annuity Beneficiary Designation
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services
F-01765 TEFAP Food Pantry Self-Assessment Tool
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-01651 Employee Information
F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist)
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-44125 Antituberculosis Therapy Program - Follow-up on Therapy
F-01454C IRIS Program Withdrawal Letter – No Contact
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB)
F-01812 Wisconsin Medicaid Program Nursing Home Cost Report
F-26100 Client Rights Limitation or Denial Documentation
F-00023 Case Management Agency Self-Audit Checklist
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment
F-01182 Declaration of Supervision for Nonbilling Providers
F-01207A IRIS Fiscal / Employer Agent Quality Management Plan Tracking
F-02205 EMS Instructor II Evaluation
F-80976 Employment and Education History Summary
F-21336 Consent for Exchange of Information with Local Educational Agency
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request
F-62495 Compliance Statement
F-13393 Trading Partner 835 Designation
F-00236A Request for a State Fair Hearing - ADRC
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus
F-00565 County Performance Plan (CPP)
F-00098 Summary of Information Letter
F-00417 AODA Prevention Services Recertification Application - DHS 75.04
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-01931 Wisconsin EMS AEMT Training Record - AEMT Refresher Requirements
F-62027 Report of Hours Worked - Registered Nurse / Night
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure
F-01601B ISP Line Item Detail Budget
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21
F-10154 Statement of Identity for Children Under 18 Years of Age

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Last Revised: July 28, 2017