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-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application DPH
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-80464 Physical and Capital Inventory Compliance Certification DES
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) DQA
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-22541 Incident Report - Medicaid Waiver Programs DMS
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs DQA
F-02573 Prior Authorization Drug Attachment for Wakix DMS
F-01261 Fraud Statement - IRIS Program DMS
F-01721 Instructions-Calculating CLTS Foster Care Room and Board Expenses DMS
F-19002 Request to Reduce QUEST Card Balance DMS
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day DQA
F-02109B CBRF – Established Provider Licensure Application Checklist DQA
F-01165 Newborn Report DMS
F-01588 Application for Available Beds DMS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-01947 IRIS Participant Education Manual: Acknowledgement DMS
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS
F-01546 IRIS Consultant Agency (ICA) Biography DMS
F-11129A Federally Qualified Health Center Cost Report Completion Instructions DMS
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-02107 Family Adult Day Care Center – Applicant Compliance Statement DQA
F-00759 Business Associate Agreement - With Contract DES
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-42029 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) and/or Varicella Vaccine DPH
F-00538 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 DQA
F-82021 Researcher's Request for Confidential Records or Human Subjects Research OLC
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer DCTS
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-00060 Declaration to Physicians (Living Will) DPH
F-00086 Authorization for Final Disposition DPH
F-00036 Power of Attorney for Finance and Property DPH
F-69312 Surveyor Notes Worksheet CMS-807 DQA
F-44161 WIC Rights and Responsibilities DPH
F-00780 Options Counseling Tip Card DPH
F-01112 HealthCheck Verification Card DMS
F-45029 School Food Safety Program Inspection Report DPH
F-10075 Wisconsin Well Woman Medicaid Application and Renewal DMS
F-10112 Medicaid Disability Application DMS
F-40040 Envelope - Vendor and Integrity Unit #9 DPH
F-13038 Notice of Intent to File a Lien DMS
F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report DPH
F-10182 BadgerCare Plus Application Packet DMS
F-10076 SeniorCare Application DMS
F-01320 Lead Test Kit Documentation DPH
F-40041 Certification and Food Package Pick-Up DPH
F-45029i Instructions For School Food Safety Plan DPH

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Last Revised: March 26, 2019