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-82064 Background Information Disclosure (BID)
F-21077 Autism Treatment Services Criteria Checklist Instructions
F-16076 FoodShare Six-Month Report and Instructions
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-01105 PreNatal Care Coordination Pregnancy Questionnaire
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-02112 2017 Community Support Program (CSP) Survey Worksheet
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
F-02167 Program Participation System (PPS) PORTAL Report Feedback
F-80015 Summary of Depository Funds Annual Report
F-02046 IRIS Financial Projections Template
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure
F-47119 Ambulance Report
F-11133 Personal Care Screening Tool (PCST)
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use
F-00681DDD IRIS (Include, Respect, I Self-Direct) Three (3) Consultant Agency Options
F-00115 Wisconsin Uniform Placment Criteria (WI-UPC) Adult Placement Scoring Instrument
F-01655 Enrollment Discrepancy Report
F-00005 Senior FMNP Agency Application to Participate
F-01556 Medicaid Cost Share Letter - Initial
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-01275 IRIS Provider Board Member Disclosure
F-01199 Optional School-Based Services Activity Medication Administration
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age)
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request
F-01204B Letter - IRIS Program Notice of Action - Limit
F-02250 Quarterly Program Integrity Report
F-80952 Contingency Plan - Health and Human Services Agencies
F-62416 Community-Based Residential Facility (CBRF) – Initial Licensure Checklist
F-20922 Determination of No Active Treatment (NAT) Rating
F-62654 Home Health Agency Licensure Survey Exit Conference Guide
F-16024 FoodShare Notice of Disqualification
F-62370 Significant Change in Health Screening Instrument Model Form
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions
F-00596a PPS Mental Health Deskcard
F-11076B Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for Continuing Services
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-10188 Undue Hardship Waiver Decision for Facility
F-00335 Voluntary Agreement for Crisis Stabilization Services
F-01454F IRIS Program Withdrawal Letter - Death
F-00202 Individual Service Plan - Community Recovery Services (CRS)
F-01902 Symptomatic Urinary Tract Infection (SUTI)


Last Revised: May 22, 2018