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-12022 Managed Care Program Provider Appeal
F-62156 Living Unit Direct Care Staff Report - Day Shift
F-11041 Private Duty Nursing Prior Authorization Acknowledgment
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification
F-10150A Your Rights and Responsibilities for Health Care
F-00264 Personal Care Agency Surveyor Guide
F-00142 Prior Authorization / Drug Attachment for Synagis®
F-01949 ADRC Annual Update
F-00015 Final Occupancy Inspection Checklist
F-01827 Application for Reduction of Cost Share
F-01628 OARS Enrollment Letter
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume
F-43009 Diabetes Emergency Action Plan
F-01302 Weekly Driver's Vehicle Inspection Report
F-01205 IRIS Participant Education: Self-Direction Responsibilities
F-22433 Request for a Hearing, Wisconsin Birth to 3 Program
F-01949A Tribal ADRS Annual Update
F-00016 Wall Closure Inspection Checklist
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs
F-01621 Smoking Cessation Data Collection
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation
F-43013 Diabetes Medical Management Plan
F-01309 IRIS Program Orientation and Enrollment Checklist
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement
F-01205A IRIS Participant Education: Health and Safety - Incident Reporting
F-22468 Application for Services Office for the Blind and Visually Impaired
F-01068H General Pediatric Clinic - 18 Month Visit
F-00922 Behavioral Health Integrated Care Health Home Certification Application
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter
F-20934 Court Ordered Assessment and Plan Report
F-01389B MHSIP Family Satisfaction Survey
F-02306 Application for Telecommunication Assistance Program (TAP)
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-62457 Request for Permission to Start Construction for Footings and Foundations
F-00639 Agency Data Security Staff User Agreement
F-11237 Specialized Medical Vehicle Providers Affidavit
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs
F-00233 Renewal Summary Letter
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist
F-00079 Prior Authorization Drug Attachment for Modafinil and Nuvigil
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-62022A Instructions for Report of Hours Worked and Resident Census Forms
F-01750 Request for IMD Rebalancing Initiative Funding – Detail by Member


Last Revised: May 22, 2018