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-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-62603 Adult Day Care and Family Adult Day Care Background Character Verification DQA
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-60945 Adult Family Home Initial Licensure Application DQA
F-80762 Store Inventory Reconciliation Worksheet DES
F-01954 Wisconsin EMS Training Record NCCP AEMT Refresher Requirements DPH
F-02593 Rapid Testing Log DPH
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information DMS
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan DMS
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program DPH
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-01256 FoodShare Employment and Training (FSET) - Discuss FSET Participation DMS
F-01761 Intoxicated Driver Program Self-Evaluation DCTS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-02106B Adult Day Care Center – Established Provider Certification Application Checklist DQA
F-00315 Written Prior Notice DMS
F-01634 Workplace Wellness Grant Program Application DPH
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet DQA
F-40076 Women, Infants, and Children (WIC) Nutrition Program Employer Statement DPH
F-00989C Summary of Development Child’s Positive Social Emotional Skills (IFSP) DMS
F-02282 Resident Relocation Roster DMS
F-22191 Pre-Admission Screen and Resident Review (PASARR) Level 1 Screen DCTS
F-01430 Prior Authorization Drug Attachment for Xyrem DMS
F-62274A Personal Care Agency Consent for Home Visit DQA
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-01407 Checklist (Astma Care and Environmental Strategies) DPH
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget DPH
F-47463B EMT - Basic Operational Plan Components DPH
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding DMS
F-80112 Vendor Validation DES
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License DPH
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-44013 Lead-Based Paint (LBP) Investigation Summary Report DPH
F-00114 EMS Service Director License Proxy for Individuals DPH
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review DPH
F-01207 IRIS Fiscal Employer Agent Quality Management Plan DMS
F-02314E Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation for Annual Employee Screening DPH
F-01682 Wisconsin State Certified Peer Specialist Trainer Application DCTS
F-02288 WisCaregiver Career Program: Registration Agreement DQA
F-00262 Personal Care Agency Application Materials Checklist DQA

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Last Revised: March 26, 2019