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-00681DR IRIS (Include, Respect, I Self-Direct) Two (2) Consultant Agency Options
F-00539A General Support and Service Coordination Rate Certification Worksheet
F-80013 Petty Cash Fund Annual Report
F-02026 Ethnicity and Race Selection
F-00154 Wisconsin Consultative Examination Inquiry
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing
F-13151 HIPAA Privacy Amendment Request
F-62030 Resident Census
F-11129B-H Federally Qualified Health Center Cost Report Forms
F-47097 Application for Registration of X-Ray Devices
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget
F-10193 Undue Hardship Waiver Request
F-00681CCC Family Care - Managed Care Organization (MCO) Four (4) Options
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist
F-01205M IRIS Participant Education: Restrictive Measures
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12
F-00681D IRIS (Include, Respect, I Self-Direct) Two (2) Consultant Agency Options
F-00334 Money Follows the Person (MFP) - Participant Reporting
F-42024 Vaccine Fahrenheit Temperature Log
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program
F-22538 Consent to Film or Tape
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice
F-01205B IRIS Participant Education: Budget Amendments
F-00219 Self-Employment Income Report: Farm Business
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-01556 Medicaid Cost Share Letter - Initial
F-00335 Voluntary Agreement for Crisis Stabilization Services
F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-10108 Medicaid Manual Notice for Cost of Care Contribution
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment
F-01205C IRIS Participant Education: One-Time Expense Requests
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions
F-01068J General Pediatric Clinic - Preschool Visit
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTSS
F-01204B Letter - IRIS Program Notice of Action - Limit
F-02250 Quarterly Program Integrity Report
F-00646 Emergency Medical Service Training Center - Training Permit Eligibility Certification
F-80952 Contingency Plan - Health and Human Services Agencies
F-62416 Community-Based Residential Facility (CBRF) – Initial Licensure Checklist
F-20920 Formula to Determine Amount of Income Available to Pay for Room and Board In Substitute Care
F-62654 Home Health Agency Licensure Survey Exit Conference Guide
F-00098 Summary of Information Letter
F-16023 Striker Evaluation
F-62370 Significant Change in Health Screening Instrument Model Form

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Last Revised: May 22, 2018