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-00321 OBVI Initial Interview Assessment DPH
F-00777 MAPT Vendor Related Allocation Formula DMS
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-43013 Diabetes Medical Management Plan DPH
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-80464 Physical and Capital Inventory Compliance Certification DES
F-21343A Alzheimer's Family and Caregiver Support Program (AFCSP) Financial Eligibility Screen - Worksheets 1 and 2 DPH
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS
F-02574 Wisconsin Assistive Technology Advisory Council Application DPH
F-01210A IRIS Budget Amendment Provider Quote Comparison DMS
F-62588 Feeding Assistant Training Program Application DQA
F-16028 Notice of FoodShare Overissuance DMS
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure DMS
F-02109A CBRF – Established Provider Licensure Application DQA
F-62158 Living Unit Direct Care Staff Report - Night Shift DQA
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other DMS
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet OS
F-47125 Emergency Medical Technician - Intermediate Training Permit Application DPH
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-01546 IRIS Consultant Agency (ICA) Biography DMS
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program DPH
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS
F-02107 Family Adult Day Care Center – Applicant Compliance Statement DQA
F-40310 Adult Oral Health Screening DPH
F-82018C Work Time Absence Record DES
F-25206 Petition for Capias DCTS
F-02047 IRIS Financial Reporting Template DMS
F-01314 IRIS Program Employment Checklist DMS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-02558 Family Care Member Out-of-County Notification DMS
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 DQA
F-00049 Asbestos Principal Instructor Application DPH
F-00401 Prior Authorization/Preferred Drug List (PA/PDL) for Expedited Emergency Supply Request DMS
F-01200 IRIS Program Cost Share Repayment Agreement DMS
F-13470 Claim Form Attachment Cover Page DMS
F-01642 OBVI Orientation and Mobility Screening DPH
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-00236 Request for a State Fair Hearing - MCO DMS
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation DMS
F-02384 Syndromic Surveillance Data Use Application DPH
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request DQA

Pages

Last Revised: March 26, 2019