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-00922 Behavioral Health Integrated Care Health Home Certification Application
F-01421 WISEWOMAN Monthly Reporting for Direct Services
F-02424 National Fatality Review Case Reporting System: Access Request and Confidentiality Statement
F-01389B MHSIP Family Satisfaction Survey
F-25615 Supervised Release Rules
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI)
F-82006 Employment Application and Resume
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation
F-62692 Feeding Assistant Training Program Primary Instructor Application
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information
F-11237 Specialized Medical Vehicle Providers Affidavit
F-00479 Child Outcomes Fidelity Self-Assessment
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs
F-00355 Healthiest Wisconsin 2020 Implementation Plan Endorsement
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery
F-02106 Adult Day Care Center
F-02052 Asbestos Abatement Project Log
F-01767 TEFAP Shelter Self-Assessment Tool
F-62022A Instructions for Report of Hours Worked and Resident Census Forms
F-44161A WIC Cardholder Rights and Responsibilities
F-00180 WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Entities
F-45023 Certificate - Use of Depleted Uranium under General License
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement
F-01205M IRIS Participant Education: Restrictive Measures
F-00989P Individualized Family Service Plan Team Signature (IFSP)
F-29315 Declaration of Income and Assets, and State Residency Instructions
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen
F-25614 Conditional Release Rules and Conditions
F-01412 Pre-Assessment Questionnaire
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification
F-16029 FoodShare Wisconsin Repayment Agreement
F-00043 Communication to Local Educational Agency Regarding Child Referral
F-00852 Children’s Long-Term Support (CLTS) Waivers Change Report
F-13066 Claim Refund
F-00569 Request for Waiver of Administrative Rule for Licensure
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets
F-20935 Status Report to Court for Plan Compliance
F-02208 Assisted Living Facility Self-Report
F-80882 CARS Contract Variance Correction
F-62646 Home Health Agency (HHA) Patient Rights Statement Review
F-01983 Self-Employment Income Worksheet: Business Capital Gains or Losses (Form 4797)
F-62316 Hospice Patient Rights
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-10190 Medicaid Issuer of Annuity - Notice of Obligation
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate
F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive)

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Last Revised: May 22, 2018