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-20448 Request for Medicaid Administrative Funds - Staff Position
F-01002 HealthCheck Individual Health History
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint
F-00724 Contract Performance - Payment Bond Form
F-00543A File Review Checklist
F-00681L Partnership - Three (3) Managed Care Organization (MCO) Options (Large Print)
F-00385 Nurse Aide Training - Student Waiver Request
F-02193 Verifying Tax-Exempt Income for Live-In Care Providers
F-62608 Request for Use of Medical Restraints
F-01744 Vaccine Restitution Policy - Agreement
F-62236 Hospice Clinical Record Review
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-11306 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-47463C Intermediate Technician Operational Plan Components
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA)
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other
F-01309 IRIS Program Orientation and Enrollment Checklist
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application
F-00024 HSRS Core Summary Report
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services
F-01573 Log of Ice Arena Air Quality
F-44003 Lead-Safe Renovator Application
F-01319B IRIS Denial of Enrollment Request
F-40072 8 Week Activity Log
F-22685 Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment
F-01205C IRIS Participant Education: One-Time Expense Requests
F-21076 Informed Consent - Children's Long-Term Support Functional Screen
F-01068J General Pediatric Clinic - Preschool Visit
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTSS
F-00646 Emergency Medical Service Training Center - Training Permit Eligibility Certification
F-02371 Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement
F-83292 Small Business Concern Feedback
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-80025 Forms / Publications Order
F-01989 Renewal Application – Individual Lead Disciplines
F-13151 HIPAA Privacy Amendment Request
F-62069 Home Health Agency Complaint Report
F-11129B-H Federally Qualified Health Center Cost Report Forms
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-11019 Prior Authorization / Physician Otological Report (PA/POR)
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months
F-10114 Medicaid Disability Redetermination Report
F-00236B Request for a State Fair Hearing - IRIS
F-01765 TEFAP Food Pantry Self-Assessment Tool
F-00098 Summary of Information Letter
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-47128 Emergency Medical Technician - Basic Training Permit Application

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Last Revised: May 22, 2018