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-00596a PPS Mental Health Deskcard DCTS
F-44017 Asbestos Application - Individual DPH
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 DQA
F-00989B Summary of Development (IFSP) DMS
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program DMS
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook DCTS
F-21225A Program Participation System (PPS): B-3 Module DMS
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement DPH
F-80130 Financial Information  DES
F-02119 Nurse Aide Training Program – Classroom / Laboratory Specifications DQA
F-02706 Recovery Residence Registry Application DQA
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years DMS
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-02287 Vaccine Return - Request for Authorization to Return DPH
F-60367 Community Advisory Committee Documentation DQA
F02637 Requesting FSIA Access During COVID-19 Health Emergency DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-01726 Basic Equipment List for Nurse Aide Training Programs DQA
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-02538A CLTS Provider Cost-Based Outlier DMS
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup DMS
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA
F-43006 Health Care Employer Assurance for J-1 Visa Waiver Applications DPH
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 DQA
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00316 Child Enrollment Status Regarding Birth to 3 Program DMS
F-01414 How Did We Do? DPH
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-62654 Home Health Agency Licensure Survey Exit Conference Guide DQA
F-02763 Acute Hospital Care at Home Program: Emergency Request for Approval DQA
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-44019A Immunization Assessment DPH
F-62318 Hospice Quality Assessment and Performance Improvement Review DQA
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline DMS
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility DCTS
F-47463A First Responder Operational Plan Components DPH
F-02601 Wisconsin 1-2 Bed Adult Family Home (AFH) Application DMS
F-01354 OARS Individual Service Plan (ISP) DCTS
F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox®) to Treat Chronic Migraines DMS
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-02106C Adult Day Care Center – New Provider Certification Application DQA

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Last Revised: March 26, 2019