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-47463B EMT - Basic Operational Plan Components DPH
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds) DMS
F-00989J Transition Plan - Turning 3 Years Old (IFSP) DMS
F-02377 Supported Decision-Making Agreement DPH
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-10187 Divestment Penalty and Undue Hardship Notice DMS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-02217 Affidavit for Supplemental Nutrition Assistance Program – Puerto Rico DMS
F-00479 Child Outcomes Fidelity Self-Assessment DMS
F-42016 Authorization for Release of Confidential HIV Test Results DPH
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral DPH
F-02068 Request to Establish a Children's COP Risk Reserve DMS
F-25527 Request for Increased Contract Allocation DCTS
F-62645B Drug Repository Program: Donation Record DQA
F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2 DES
F-01769 TEFAP Soup Kitchen Self-Assessment DPH
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility DMS
F-02230 County Agency Children's Community Option Program (CCOP) Annual Plan Update DMS
F-00480 Child Outcomes Summary DMS
F-42017 Wisconsin Initial Refugee Health Assessment DPH
F-10096 Community Spouse Asset Share DMS
F-01223 WISEWOMAN Case Management DPH
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report DQA
F-25614 Conditional Release Rules and Conditions DCTS
F-62645C Drug Repository Program: Destruction Record DQA
F-80462 Capital Asset Summary DES
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-02574 Wisconsin Assistive Technology Advisory Council Application DPH
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-01341 Pre-Release from Institution Checklist (CM Checklist) DCTS
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-21189 Rights of Detention DCTS
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) DPH
F-01205B IRIS Participant Education: Budget Amendments DMS
F-62586 Challenge Exam Applicant Nurse Aide / Medication Aide DQA
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure DMS
F-16014 Notice of Program Violation DMS
F-02108C Adult Family Home – New Provider Licensure Application DQA
F-01068F General Pediatric Clinic - 12 Month Visit DMS
F-62092 Hospital Certificate of Approval Application DQA
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-00915A Wisconsin Birth to 3 Program - Request for Data Discussion Certificate of Attendance DMS
F-45023 Certificate - Use of Depleted Uranium under General License DPH
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-01545 IRIS Fiscal Employer Agent (FEA) Biography DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-44126 Antituberculosis Therapy Program Medication Refill Request DPH


Last Revised: March 26, 2019