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-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) DPH
F-21336 Consent for Exchange of Information with Local Educational Agency DMS
F-25393A Petition for Supervised Release DCTS
F-80881 Profile ID Request (CARS) DES
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS
F-16023 Striker Evaluation DMS
F-02140 Urgent Services Agreement DPH
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DMS
F-01955 Wisconsin EMS Training Record Critical Care Paramedic Refresher Record DPH
F-01352 Background Check Appeal Request - IRIS Program DMS
F-00046 Family Care Program - Enrollment DPH
F-01205C IRIS Participant Education: One-Time Expense Requests DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-16024 FoodShare Notice of Disqualification DMS
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice DMS
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-02634C Residential Care Apartment Complex (RCAC) Initial Survey Checklist DQA
F-04002 School Report to Local Health Department DPH
F-00047 Designated Asbestos Coordinator DPH
F-00657 Nurse Aide Training Program: Military Training Verification DQA
F-01206 IRIS One-Time Expense Request DMS
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-00950 Partnership Coverage Decision Letter DMS
F-11042 Prior Authorization Amendment Request DMS
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist DQA
F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-01580 Noncompliance Roster DPH
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation DPH
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-01319B IRIS Denial of Enrollment Request DMS
F-25392 Petition for Re-Examination DCTS
F-02412 BioSense Platform Organization Security and Confidentiality Policy Agreement DPH
F-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-02208 Assisted Living Facility Self-Report DQA
F-21353i CLTS One Time High-Cost Notification Instructions and Typical Ranges DMS
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-00513 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 DQA
F-05260 Letter of Non-Marriage Application DPH
F-00336 Tickborne Rickettsial Disease Case Report DPH
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-62687 Nurse Aide Training Program - Trainer Application DQA
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS

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Last Revised: March 26, 2019