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.
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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 Location |
|---|---|---|---|
| F-11088 | Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) | DMS | None |
| F-00688 | Referral to Wisconsin Birth to 3 Program | DMS | None |
| F-44621 | WIC Stock Price Survey | DPH | None |
| F-10190 | Medicaid Issuer of Annuity - Notice of Obligation | DMS | None |
| F-01391B | Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook | DCTS | None |
| F-00519 | Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 | DQA | None |
| F-42011 | Interjurisdictional Tuberculosis Notification - Follow-up | DPH | None |
| F-01915A | Member Request Gap Filling Eligibility Determinations Supplemental Letter | DMS | None |
| F-10098 | Medicaid Member Asset Allocation Notice | DMS | None |
| F-82003 | Denial of Researcher Access To Health Care Records | OLC | None |
| F-00367G | Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years | DMS | None |
| F-25904 | Admission to Caseload - Revocation | DCTS | None |
| F-02034 | Aging/ADRC Integration Funding Budget Worksheet | DPH | None |
| F-01345 | Special Care Environment Working Document | DPH | None |
| F-62680 | Home Health Agency Clinical Record Review | DQA | None |
| F-00236B | Request for a State Fair Hearing - IRIS | DMS | None |
| F-21189 | Rights of Detention | DCTS | None |
| F-01891 | New Employment Reporting – FoodShare Employment and Training (FSET) Program | DMS | None |
| F-01206 | IRIS One-Time Expense Request | DMS | None |
| F-62440 | Report of Hours Worked - Other Direct Care Nurse Aide / Day | DQA | None |
| F-02538A | CLTS Provider Cost-Based Outlier | DMS | None |
| F-16015 | Notice of Approval of Benefits/Positive Change in Benefits | DMS | None |
| F-01628 | OARS Enrollment Letter | DCTS | None |
| F-02463 | Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement | DPH | None |
| F-00017 | Blood Lead Lab Reporting | DPH | None |
| F-01068i | General Pediatric Clinic - 24 Month Visit | DMS | None |
| F-01556D | IRIS Program Letter – Disenrollment | DMS | None |
| F-00922 | Behavioral Health Integrated Care Health Home Certification Application | DMS | None |
| F-45016 | Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope | DPH | None |
| F-02382 | HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet | DMS | None |
| F-11042 | Prior Authorization Amendment Request | DMS | None |
| F-01454A | IRIS Program Withdrawal Letter – Financial or Functional Eligibility | DMS | None |
| F-00614 | Physician, Physician Assistant, and Registered Nurse Equivalency Application | DPH | None |
| F-44024A | WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women | DPH | None |
| F-02067 | Women, Infants, and Children (WIC) Staff Training Record | DPH | None |
| F-10150B | Your Rights and Responsibilities for FoodShare | DMS | None |
| F-00989-Packet | Individualized Family Service Plan (IFSP) Packet | DMS | None |
| F-00470 | Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12 | DQA | None |
| F-40093 | Annual ROSIE User Security and Confidentiality Agreement | DPH | None |
| F-62380 | Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application | DQA | None |
| F-80857 | Special CARS Run request | DES | None |
| F-22637 | Interagency Notification -Termination of Community Waiver Participation | DMS | None |
| F-02011 | Fluoride Mouth Rinse Program Annual Report | DPH | None |
| F-62641 | Hospice Inpatient Symptom Management and Respite Contract or Agreement Review | DQA | None |
| F-02602 | 1-2 Bed Adult Family Home Certification Application Request | DMS | None |
| F-11044 | Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) | DMS | None |
| F-01454B | IRIS Program Withdrawal Letter – Health and Safety | DMS | None |
| F-00615 | Change Project Report and Instructions | DPH | None |
| F-44063 | Lead (Pb) Principal Instructor Application | DPH | None |
| F-40054A | Confidential Birth Defects Registry – Request to Remove Identifiers | DPH | None |
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Last Revised: March 26, 2019
