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-00989L Summary of Services (IFSP) DMS
F-02412 BioSense Platform Organization Security and Confidentiality Policy Agreement DPH
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance DCTS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding DMS
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility DMS
F-40098 Worksite Wellness Kit Survey and Request DPH
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral OIG
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-01220 WISEWOMAN Healthy Lifestyle Assessment DPH
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) DPH
F-02074 Medicare Other Coverage Discrepancy Report DMS
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application DCTS
F-01275 IRIS Provider Board Member Disclosure DMS
F-80115 Operating Budget DES
F-02666 Prior Authorization Drug Attachment for Headache Agents, Acute Treatment DMS
F-20572 Request for State Public Funding for Non-Residents DCTS
F-01997 Children's Community Options (CCOP) Reconciliation Packet DMS
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-02548 BadgerCare Plus Health Survey DMS
F-01708 Case Management Comprehensive Assessment DPH
F-02108D Adult Family Home – New Provider Licensure Application Checklist DQA
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist DQA
F-01012 Reimbursement Request for a PASRR Level I Screen DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-01580 Noncompliance Roster DPH
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-29315 Declaration of Income and Assets, and State Residency Instructions DMS
F-00784 Personal Care Agency Client Rights DQA
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-01549 IRIS Certification Designation of Confidential and Proprietary Information DMS
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-00780A Options Counseling Tip Card Supplement DPH
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 DQA
F-10114 Medicaid Disability Redetermination Report DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-02193 Verifying Tax-Exempt Income for Live-In Care Providers DMS
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years DMS
F-80976 Employment and Education History Summary DES
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) DPH
F-02052 Asbestos Abatement Project Log DPH
F-62645B Drug Repository Program: Donation Record DQA
F-00236B Request for a State Fair Hearing - IRIS DMS
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs DPH
F-00054 Request for Waiver of Education / Experience Requirements (ADRC) DPH
F-16038 Administrative Disqualification Hearing Notice DMS
F-01578A IRIS SharePoint - Request for User Setup DMS

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Last Revised: March 26, 2019