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 Language
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request English
F-01681 Comprehensive Community Services (CCS) Technical Assistance Survey English
F-47119 Ambulance Run Report (PDF, 110 KB) English
F-00714 Business Associate Agreement - County or Tribal Contract English
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) English
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels English
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding (PDF, 25 KB) English
F-01312 IRIS Provider Application English
F-01545 IRIS Fiscal Employer Agent (FEA) Biography English
F-00681C Family Care - Managed Care Organization (MCO) Two Options English
F-01408 Asthma Control Summary English
F-00261 Personal Care Agency Personnel Record Review English
F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI) (PDF, 21 KB) English
F-80190 Travel Reimbursement Request Non-State Employee English
F-21056 Variance Request for Adult Day Care Located within or on the Grounds of a Nursing Home/Institution English
F-00124 Wisconsin Termination Domestic Partnership Certificate Application English
F-01105 Pre-Natal Care Coordination Pregnancy Questionnaire English
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) English
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet English
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval English
F-00518 CSAS Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 English
F20418 Agency Application for Access to Web-Based Personal Care Screening Tool English
F-02036 Disaster Response Interpreter Training Application English
F-00049 Asbestos Principal Instructor (PDF, 30 KB) English
F-62603 Adult Day Care and Family Adult Day Care Background Character Verification English
F-01765 TEFAP Food Pantry Self-Assessment Tool English
F-62233 Hospice Personnel Record Review English
F-44161A WIC Cardholder Rights and Responsibilities English
F-13148 Wisconsin Medicaid HIPAA Privacy Access Request (PDF, 178 KB) English
F-47463B Emergency Medical Techician (EMT) - Basic Operational Plan Components (PDF, 26 KB) English
F-11129A Wisconsin Medicaid - Federally Qualified Health Center Cost Report Completion Instructions (PDF, 102 KB) English
F-45019 Reciprocity Privileges Checklist (PDF, 92 KB) English
F-11019 Prior Authorization / Physician Otological Report (PA/POR) English
F-00367H CLTS FS, Age-Specific ADL / IADL, 6 to 9 Years (PDF, 32 KB) English
F-10114 Medicaid Disability Redetermination Report (PDF, 222 KB) English
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment English
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change English
F-44323 WIC Stock Price Survey – Pharmacy Only English
F-01468 IRIS Program Start Date Letter – New Participant English
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up (PDF, 87 KB) English
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary English
F-29321 COP Cost-Share Worksheet #2 English
F-00219 Self-Employment Income Report - Farmer English
F-01270 Comprehensive Community Services Non-Traditional Approval English
F-22433 Request for a Hearing, Wisconsin Birth to 3 Program English
F-01198 Wisconsin Medicaid - Optional School-Based Services Activity Log Nursing / Therapy Medical Services English
F-20822 County Review of Nursing Home, IMD or ICF/MR Referrals English
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) English
F-00891 Abuse and Neglect Prevention Training - DVD Request (PDF, 20 KB) English
F-02257 Temperature Excursion Incident Report - WIsconsin Vaccines for Children Program (VFC) English

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Last Revised: July 28, 2017