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-00842 Pharmacy Services Lock-In Program - Program Summary DMS
F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators DPH
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS
F-01570 Ice Arena Equipment Maintenance Log DPH
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13 DQA
F-44013 Lead-Based Paint (LBP) Investigation Summary Report DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification DPH
F-40071 Children's Physical Activity Chart DPH
F-02346 Training Course Accreditation Application Lead Disciplines DPH
F-01204D Letter – IRIS Program Notice of Action – Termination DMS
F-22541 Incident Report – IRIS DMS
F-02106 Adult Day Care Center – Applicant Compliance Statement DQA
F-62688 Feeding Assistant Training Program Trainer Application DQA
P-01391 Mental Health Statistics Improvement Program (MHSIP) Adult Data Workbook DCTS
F-02022 Claims Audit Report for Managed Long-Term Care MCOs DMS
F-02639 Time and Task Pretest DPH
F-01204E Letter – IRIS Program Notice of Action – Functional Eligibility DMS
F-00261 Personal Care Agency Personnel Record Review DQA
F-22550 Birth to 3 Program Parental Cost Share DMS
F-02107 Family Adult Day Care Center – Applicant Compliance Statement DQA
F-62692 Feeding Assistant Training Program Primary Instructor Application DQA
F-01203 IRIS Provider Education – Health and Safety – Incident Reporting DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-02643 Student Nurse Aide Skills Checklist DQA
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-20009 Complaint Report DCTS
F-01159 Commercial Other Coverage Discrepancy Report DMS
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report DQA
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program DMS
F-00987D EMS Service Operational Plan Advanced Skills Addendum (Paramedic) DPH
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-11090 Mental Health Day Treatment Functional Assessment DMS
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report DPH
F-00676A Youth Transition Post-Test DPH
F-45003 Occupational Exposure Record Per Monitoring Period DPH
F-02491 FoodShare Buy and Make Food Separately DMS
F-10191 Medicaid Annuity Beneficiary Designation DMS
F-01556 Medicaid Cost Share Letter - Initial DMS
F-00513 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 DQA
F-43009 Diabetes Emergency Action Plan DPH
F-21353 Children's Long-Term Support Waiver High-Cost Request DMS
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months DMS

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Last Revised: March 26, 2019