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 Language
F-80115 Operating Budget English
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs English
F-02046 IRIS Financial Projections Template English
F-62588 Feeding Assistant Training Program Application English
F-00236A Request for a State Fair Hearing - ADRC English
F-00681CC Family Care - Managed Care Organization (MCO) Three Options English
F-62164 Report of Hours Worked - Licensed Practical Nurse / Day English
F-13072 Noncompound Drug Claim English
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) English
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy English
F-00646 Emergency Medical Service Training Center - Training Eligibility Certification English
F-02086 Histoplasmosis Case Worksheet English
F-80122 Journal Voucher English
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months (PDF, 19 KB) English
F-02047 IRIS Financial Reporting Template English
F-62589 Telehealth Application – Initial Approval English
F-00236B Request for a State Fair Hearing - IRIS English
F-00681CCC Family Care - Managed Care Organization (MCO) Four Options English
F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening English
F-13073 Compound Drug Claim English
F-11090 Mental Health Day Treatment Functional Assessment English
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography English
F-00514 CSAS Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 English
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format English
F-10108 Medicaid Manual Notice for Cost of Care Contribution English
F-00681CR Family Care - Two (2) Managed Care Organization (MCO) Options-Rock English
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request English
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter English
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility English
F-01204C Letter - IRIS Program Notice of Action--Reduction English
F-29316 COP Initial and / or Continuing Financial Eligibility Determination Worksheet for a Single Applicant / Participant (PDF, 30 KB) English
F-00100 State Vital Records Cover Letter English
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement English
F-21353 Community Options Program (COP) Exceptional Expense Request English
F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement English
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit (PDF, 235 KB) English
F-02250 Quarterly Program Integrity Report English
F-80962 New Capital Asset Record English
F-62418 Adult Day Care Initial Certification Application English
F-00316 Child Enrollment Status Regarding Birth to 3 Program English
F-20812 SSI-E Natural Residential Setting Application Checklist English
F-62494 Health Care Facility Construction Documentation Checklist English
F-00191 Certified Outpatient Clinic Request for a Branch Office English
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits English
F-62025 Report of Hours Worked - Registered Nurse / Evening English
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) English
F-00466 CSAS Ambulatory Detoxification Service Recertification Application - DHS 75.08 English
F-01714 DHS 140 Review of Required Local Public Health Authority Level II/III Tool English
F-01710 Home Health Agency Initial Licensure Checklist English
F-01604 Telehealth Application – Annual Review of Approval English

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Last Revised: July 28, 2017