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-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 & 61.79 English
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan English
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request English
F-01954 NCCP AEMT Refresher Requirements - Wisconsin EMS Training Record (PDF, 192 KB) English
F-01293D Participant Fiscal Employer Agent (FEA) – Transfer Checklist English
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire English
F-47097 Application for Registration of Ionizing Radiation Sources (PDF, 29 KB) English
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) English
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels English
F-10144 Life Insurance Inquiry English
F-01310A IRIS Program Conflict of Interest Disclosure - Participant English
F-00634B Records Access Log, Birth to 3 Program English
F-00681B Partnership - Two (2) Managed Care Organization (MCO) Options English
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification English
F-01407 Checklist English
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results English
F-22571 Caretaker Supplement Application English
F-80188 Check Distribution / Attachments English
F-01205F IRIS Participant Education: Complaints and Grievances English
F-21055 Home Modification Request for a Ramp English
F-00123 Wisconsin Declaration of Domestic Partnership Application English
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster 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-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) 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
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request (PDF, 158 KB) English
F-47463A First Responder Operational Plan Components (PDF, 19 KB) English
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan English
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources English
F-11018 Prior Authorization Request Form (PA/RF) English
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years (PDF, 26 KB) English
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion English
F-01275A IRIS Provider Executive Staff Disclosure English
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program English
F-01454E IRIS Program Withdrawal Letter – Voluntary English
F-42010 Interjurisdictional Tuberculosis Notification (PDF, 24 KB) English
F-01208A IRIS Consultant Agency Quality Management Plan Tracking English
F-29320 COP Cost-Share Worksheet #1 Instructions English
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment English
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility English
F-22191 Pre-admission Screen and Resident Review (PASARR) Level 1 Screen English
F-01197 Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation English

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Last Revised: July 28, 2017