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-01176 Prior Authorization Fax Cover Sheet DMS
F-62447 Misconduct Incident Report DQA
F-02565 Community Recovery Services (CRS) Staff Background Check Confirmation DCTS
F-01642 OBVI Orientation and Mobility Screening DPH
F-00107 Self-Employment Income Report DMS
F-01012 Reimbursement Request for a PASRR Level I Screen DMS
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares DMS
F-00784 Personal Care Agency Client Rights DQA
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 DQA
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) DPH
F-02188 Lyme Disease Case Worksheet DPH
F-10114 Medicaid Disability Redetermination Report DMS
F-01204D Letter – IRIS Program Notice of Action – Termination DMS
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years DMS
F-40054 Confidential Birth Defects Registry Report DPH
F-02157 Nurse Aide Training Program – Application for Approval Checklist DQA
F-80911 Limited Term Employment (LTE) or Project Employment Application DES
F-02700 Wisconsin COVID-19 Patient Information DPH
F-22018i HSRS Long-Term Support Module Desk Card DES
F-01942B LTC FS - Request Letter DMS
F-62646 Home Health Agency (HHA) Patient Rights Statement Review DQA
F-02614 Fraud Prevention and Investigation Program (FPIP) Fraud Year Contact Information OIG
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents DMS
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36 DQA
F-16031 Student Aid and Expense Worksheet DMS
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-62308 Authorization to Accept Personal Service and Receive Registered and Certified Mail DQA
F-02503 Vaccine for Outbreak Response Request DPH
F-13066 Claim Refund DMS
F-01648 Coverdell Stroke Care Partner Agreement DPH
F-00963 Children’s Long Term Support Reconciliation Packet DMS
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-02430 Statement About Immigration Status DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-00989L Summary of Services (IFSP) DMS
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information DMS
F-01442C IRIS Program Disenrollment Letter – No Contact DMS
F-42010 Interjurisdictional Tuberculosis Notification DPH
F-02260 Temporary QUEST Card Issuance Checklist DMS
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36 DQA
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-02080 Dementia Crisis Innovation Grants: Round Two DPH

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Last Revised: March 26, 2019