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-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-00688 Referral to Wisconsin Birth to 3 Program DMS
F-44621 WIC Stock Price Survey DPH
F-10190 Medicaid Issuer of Annuity - Notice of Obligation DMS
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook DCTS
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 DQA
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up DPH
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter DMS
F-10098 Medicaid Member Asset Allocation Notice DMS
F-82003 Denial of Researcher Access To Health Care Records OLC
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years DMS
F-25904 Admission to Caseload - Revocation DCTS
F-02034 Aging/ADRC Integration Funding Budget Worksheet DPH
F-01345 Special Care Environment Working Document DPH
F-62680 Home Health Agency Clinical Record Review DQA
F-00236B Request for a State Fair Hearing - IRIS DMS
F-21189 Rights of Detention DCTS
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program DMS
F-01206 IRIS One-Time Expense Request DMS
F-62440 Report of Hours Worked - Other Direct Care Nurse Aide / Day DQA
F-02538A CLTS Provider Cost-Based Outlier DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-01628 OARS Enrollment Letter DCTS
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-00017 Blood Lead Lab Reporting DPH
F-01068i General Pediatric Clinic - 24 Month Visit DMS
F-01556D IRIS Program Letter – Disenrollment DMS
F-00922 Behavioral Health Integrated Care Health Home Certification Application DMS
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope DPH
F-02382 HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet DMS
F-11042 Prior Authorization Amendment Request DMS
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility DMS
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application DPH
F-44024A WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women DPH
F-02067 Women, Infants, and Children (WIC) Staff Training Record DPH
F-10150B Your Rights and Responsibilities for FoodShare DMS
F-00989-Packet Individualized Family Service Plan (IFSP) Packet DMS
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12 DQA
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application DQA
F-80857 Special CARS Run request DES
F-22637 Interagency Notification -Termination of Community Waiver Participation DMS
F-02011 Fluoride Mouth Rinse Program Annual Report DPH
F-62641 Hospice Inpatient Symptom Management and Respite Contract or Agreement Review DQA
F-02602 1-2 Bed Adult Family Home Certification Application Request DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS
F-00615 Change Project Report and Instructions DPH
F-44063 Lead (Pb) Principal Instructor Application DPH
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers DPH


Last Revised: March 26, 2019