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-00596a PPS Mental Health Deskcard DCTS
F-00047 Designated Asbestos Coordinator DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-80762 Store Inventory Reconciliation Worksheet DES
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-22491 Consumer Report and Survey - OBVI DPH
F-01954 Wisconsin EMS Training Record NCCP AEMT Refresher Requirements DPH
F-62610 Nurse Aide Training Program Primary Instructor Application DQA
F-02592 Rapid Test and Controls Inventory Log DPH
F-00538 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 DQA
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist DQA
F-62236 Hospice Clinical Record Review DQA
F-02106A Adult Day Care Center – Established Provider Certification Application DQA
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-13146 HIPAA Privacy Revocation of Authorization DMS
F-01618 Client Services Agreement for Medicare Counseling DPH
F-01282 Monthly Enrollment Discrepancy Report Template - Model DMS
F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan DPH
F-00989B Summary of Development (IFSP) DMS
F-01186 Wisconsin Chronic Renal Disease Program Application DMS
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports DMS
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement DMS
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-44746 Farmers Market Nutrition Program (FMNP) - Site Observation Worksheet DPH
F-10190 Medicaid Issuer of Annuity - Notice of Obligation DMS
F-01430 Prior Authorization Drug Attachment for Xyrem DMS
F-42023 Vaccine Celsius Temperature Log DPH
F-00015 Final Occupancy Inspection Checklist DQA
F-01407 Checklist (Asthma Care and Environmental Strategies) DPH
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC DCTS
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding DMS
F-80122 Journal Voucher DES
F-00101 Authorization to Request Birth Records DMS
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters DPH
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS
F-62504 Behavioral Health Certification Section: Initial Certification Application DQA
F-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS
F-00479 Child Outcomes Fidelity Self-Assessment DMS
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services DMS
F-01246 Background Information Disclosure Addendum—IRIS DMS
F-01145 Wisconsin Hemophilia Home Care Program Residency Verification DMS
F-00311 Nursing Home MDS 3.0 Section Q Referral DQA
F-62069 Home Health Agency Complaint Report DQA
F-01572 Ice Arena Log of Pollutant Exceedance DPH
F-45021 Generally Licensed Device Inspection by Mail DPH
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS

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Last Revised: March 26, 2019