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-02209 Program Integrity Annual Survey – Health Maintenance Organizations (HMOs)
F-01804 Appointment Results Wisconsin WIC Program
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections
F-44323 WIC Stock Price Survey – Pharmacy Only
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up
F-13073 Compound Drug Claim
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting
F-29320 COP Cost-Share Worksheet #1 Instructions
F-11081 Rural Health Clinic Provider Staff Encounters
F-01201A IRIS Participant - Hired Worker Relationship Identification
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up
F-10192 Medicaid Annuity Information - Disclosure
F-00262 Personal Care Agency Application Materials Checklist
F-00124 Wisconsin Termination Domestic Partnership Certificate Application
F-62648A Personal Care Agency Sample Selection
F-00014 Ceiling Closure Inspection Checklist
F-01549 IRIS Certification Designation of Confidential and Proprietary Information
F-62318 Hospice Quality Assessment and Performance Improvement Review
F-01418 21-Day Monitoring Period Chart
F-22191 Pre-Admission Screen and Resident Review (PASARR) Level 1 Screen
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units)
F-20812 SSI-E Natural Residential Setting Application Checklist
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-62418 Adult Day Care Initial Certification Application
F-00681EEE IRIS (Include, Respect, I Self-Direct) Fiscal Employer Agent (FEA) Options
F-01068C General Pediatric Clinic - 4 Month Visit
F-00913 Annual Survey of Nursing Homes
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement
F-00681DDL IRIS (Include, Respect, I Self-Direct) Four Consultant Agency Options (Large Print)
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume
F-11134 Personal Care Prior Authorization Provider Acknowledgement
F-01623 OARS - Residential Placement Reviews
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice
F-44017 Asbestos Application - Individual
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program
F-00615 Change Project Report and Instructions
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment
F-00476 CARES Automated Systems Access Request
F-01176 Prior Authorization Fax Cover Sheet
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services
F-00219 Self-Employment Income Report: Farm Business
F-80459 Client Account Balance Report
F-62588 Feeding Assistant Training Program Application
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-62158 Living Unit Direct Care Staff Report - Night Shift
F-25392 Petition for Re-Examination
F-11048 Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission
F-10161 Statement of Citizenship and/or Identity
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation

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Last Revised: May 22, 2018