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-47141 Emergency Medical Technician-Paramedic Training Permit Application DPH
F-20920 Formula to Determine Amount of Income Available to Pay for Room & Board in Substitute Care DMS
F-00987E EMS Service Operational Plan Advanced Skills Addendum (Critical Care) DPH
F-01486 IRIS Consultant Biography DMS
F-11090 Mental Health Day Treatment Functional Assessment DMS
F-00703 Patient Side Training Report DPH
F-10192 Medicaid Annuity Information - Disclosure DMS
F-11136 Personal Care Addendum DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04 DQA
F-42017 Wisconsin Initial Refugee Health Assessment DPH
F-82009 Confidential Information Release Authorization - Generic  DES
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist DMS
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC DCTS
F-62688 Feeding Assistant Training Program Trainer Application DQA
F-01352 Background Check Appeal Request - IRIS Program DMS
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS
F-21225A Program Participation System (PPS): B-3 Module DMS
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night DQA
F-02544 Nursing Home Immediate Jeopardy (IJ) Removal Plan DQA
F-01206B IRIS One-Time Expense Request - Ramp DMS
F-01624 OARS Alternative to Revocation (ATR) Referral DCTS
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist DQA
F-02474 Active Tuberculosis (TB) Disease Follow-up Report DPH
F-01275A IRIS Provider Executive Staff Disclosure DMS
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-00049 Asbestos Principal Instructor Application DPH
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-45019 Reciprocity Privileges Checklist DPH
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTS DMS
F-01454C IRIS Program Withdrawal Letter – No Contact DMS
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 DMS
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral OIG
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable DMS
F-01359 Historical Earnings Verification Request DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-62418 Adult Day Care Initial Certification Application DQA
F-00472 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 DQA
F-40098 Worksite Wellness Kit Survey and Request DPH
F-80882 CARS Contract Variance Correction DES
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate DMS
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record DQA
F-02601 Wisconsin 1-2 Bed Adult Family Home (AFH) Application DMS
F-44212 School Report to the District Attorney DPH
F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 DQA
F-02108D Adult Family Home – New Provider Licensure Application Checklist DQA
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum DQA
F-00017 Blood Lead Lab Reporting DPH

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Last Revised: March 26, 2019