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-11022 Rural Health Clinic Statistical Data
F-01899 Central Line-Associated Bloodstream Infection (CLABSI)
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11
F-00714 Business Associate Agreement - County or Tribal Contract
F-00332 Medicaid Purchase Plan Premium Information / Payment
F-44010 Lead-Free / Lead-Safe Property Registry, Training Course, Class and Roster Database Access Application
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program
F-40074 Annual Physical Activity Record
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS)
F-22564 Authorization for Retroactive Caretaker Supplement (CTS)
F-00221B Family Care / Partnership / PACE / IRIS Program Requested Disenrollment
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-01002 HealthCheck Individual Health History
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information
F-00724 Contract Performance - Payment Bond Form
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo
F-00543A File Review Checklist
F-00040 Asbestos Course Accreditation - Renewal
F-01063 HealthCheck Family History
F-00681DDDDL IRIS (Include, Respect, I Self-Direct) Five (5) Consultant Agency Options (Large Print)
F-00107 Self-Employment Income Report
F-25393A Petition for Supervised Release
F-01407 Checklist (Astma Care and Environmental Strategies)
F-02108 Adult Family Home
F-80122 Journal Voucher
F-02059 New Carrier Insurance Disclosure Onboarding
F-13393 Trading Partner 835 Designation
F-62537 Petition for Building Code Variance
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification
F-62092 Hospital Certificate of Approval Application
F-01950 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-01788 Certification Regarding Debarment and Suspension
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections
F-00390 Incident Report - Community Recovery Services (CRS)
F-01275A IRIS Provider Executive Staff Disclosure
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine
F-11076B Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for Continuing Services
F-10188 Undue Hardship Waiver Decision for Facility
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTSS
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36
F-10096 Community Spouse Asset Share
F-01344 Strategies for Success with People Who Have Dementia-Behavior Analysis Worksheet-Model (PDF, 92 KB)
F-00004A Health and Employment Counseling - I Think I Need More Time
F-01454E IRIS Program Withdrawal Letter – Voluntary
F-02385 Vaccine Accountability -Vaccine Preventable Disease: Tetanus
F-01208A IRIS Consultant Agency Quality Management Plan Tracking
F-02288 WisCaregiver Career Program: Registration Agreement
F-22018i HSRS Long-Term Support Module Desk Card


Last Revised: May 22, 2018