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 Other Locationsort descending
F-01899 Central Line-Associated Bloodstream Infection (CLABSI)
F-60367 Community Advisory Committee Documentation
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA)
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information
F-00167 Civil Rights Complaint Consent / Release
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-01588 Application for Available Beds
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility
F-43013 Diabetes Medical Management Plan
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program
F-01220 WISEWOMAN Healthy Lifestyle Assessment
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit
F-20985 Participant Rights and Responsibilities Notification
F-16076 FoodShare Six-Month Report and Instructions
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center
F-00676A Youth Transition Post-Test
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program
F-02107 Family Adult Day Care Center
F-80462 Capital Asset Summary
F-02059 New Carrier Insurance Disclosure Onboarding
F-62608 Request for Use of Medical Restraints
F-01950 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-62274A Personal Care Agency Consent for Home Visit
F-11237 Specialized Medical Vehicle Provider Affidavit
F-47463D Intermediate Operational Plan Components
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption
F-00261 Personal Care Agency Personnel Record Review
F-80464 Physical and Capital Inventory Compliance Certification
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding
F-62610 Nurse Aide Training Program Primary Instructor Application
F-01951 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis
F-62281 Care Level Change Notice
F-11240 Case Management Provider Information
F-47463E Paramedic Operational Plan Components
F-11027 Rural Health Clinic Quarterly Cost Report
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application
F-00262 Personal Care Agency Application Materials Checklist
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-01814 County Agency Children’s Community Options Program (CCOP) Five-Year Plan
F-01210B Budget Amendment Annual Verification (BAAV) Request
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bedhold Days

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Last Revised: July 28, 2017