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-83263 Rehabilitation Review Application and Instructions
F-21078 Children's Long-Term Support (CLTS) Waivers Recertification Checklist
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals
F-80112 Vendor Validation
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request
F-62069A Personal Care Agency Complaint Report
F-47128 Emergency Medical Technician - Basic Training Permit Application
F-11041 Private Duty Nursing Prior Authorization Acknowledgment
F-00042 Knowledge Journal
F-10150A Your Rights and Responsibilities for Health Care
F-00681EEE IRIS (Include, Respect, I Self-Direct) Four (4) Fiscal Employer Agent (FEA) Options
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter
F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet
F-01205I IRIS Participant Education: Program Integrity - Conflict of Interest
F-01105 PreNatal Care Coordination Pregnancy Questionnaire
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08
F-01204D Letter - IRIS Program Notice of Action - Termination
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-80962 New Capital Asset Record
F-62528 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Checklist
F-20941 Informed Consent for Participation in Wisconsin's Money Follows the Person (MFP) Demonstration
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3)
F-16025 Disqualification Consent Agreement
F-62373 Resident Evacuation Assessment
F-00166 Service Delivery or Employment Discrimination Complaint
F-13033 Probate Claims Notice
F-11133 Personal Care Screening Tool (PCST)
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses
F-00005 Senior FMNP Agency Application to Participate
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-60367 Community Advisory Committee Documentation
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources
F-01601A CST Summary Line Item Budget

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Last Revised: May 22, 2018