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-01063 HealthCheck Family History
F-02067 Women, Infants, and Children (WIC) Staff Training Record
F-82018C Work Time Absence Record
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals
F-62546 Corporate Guardianship Program Annual Report
F-16015 Notice of Approval of Benefits/Positive Change in Benefits
F-62151 Nursing Home Residents' Rights Complaint Report
F-00588 PPS Alcohol and Other Drug Abuse Module
F-11067 Record of Actual Daily Oxygen Use
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10
F-00330 Request for Replacement FoodShare Benefits
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-01750 Request for IMD Rebalancing Initiative Funding – Detail by Member
F-01647 Coverdell Emergency Medical Services (EMS) Partner Agreement
F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices
F-00989P Individualized Family Service Plan Team Signature (IFSP)
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY)
F-44017 Asbestos Application - Individual
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement
F-01348 Determining the Weighted Care Management Rate-Direct Service Staff Worksheet
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36
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
F-01161 Abortion Certification Statements
F-01459 Tuberculosis (TB) Program Dispensary Pre-Authorization for Non-Routine TB Services
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center
F-16060C Disaster FoodShare Application – Puerto Rico Residents
F-25393 Petition for Conditional Release
F-80900A Receivables Quarterly Report
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard
F-62674A Model Balance Sheet
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request
F-00754 Wisconsin Civil Service Request for Examination Accommodations
F-11278 PreNatal Care Coordination Outreach and Management Plan
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05
F-00388 County Birth to 3 Fiscal Reconciliation Report
F-60947 Adult Day Care Initial Certification Checklist
F-01942A LTC FS - Diagnosis Verification Letter
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night
F-00193 Pediatric Referral / Communication Wisconsin WIC Program
F-60953 Adult Family Home Fire Safety Guide
F-01622 OARS Records Checklist
F-47119 Ambulance Report
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA)
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs


Last Revised: July 28, 2017