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-01352 Background Check Appeal Request - IRIS Program
F-22433 Request for a Hearing, Wisconsin Birth to 3 Program
F-01246 Background Information Disclosure Addendum—IRIS
F-01170 Written Correspondence Inquiry
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen
F-00681DDL IRIS (Include, Respect, I Self-Direct) Four Consultant Agency Options (Large Print)
F-01414 How Did We Do?
F-02230 County Agency Children's Community Option Program (CCOP) Annual Plan Update
F-80883 CARS Contract Adjustment - Extensions and Moves
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals
F-62651 Home Health Agency Calendar Worksheet - Prescribed Visits
F-16015 Notice of Approval of Benefits/Positive Change in Benefits
F-01012 Reimbursement Request for a PASRR Level I Screen
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35
F-11055 STAT-PA System Instructions
F-00553 Professional & Occupational License Application & Affidavit
F-00407 Financial Records Request
F-00989-Packet Individualized Family Service Plan (IFSP) Packet
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-80900 Receivables Annual Report
F-62651A Personal Care Agency Calendar Worksheet - Prescribed Visits
F-62320 Hospice Survey Information
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-00787 Prior Authorization - Requirement Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services
F-11062 Prior Authorization / Environmental Lead Inspection
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information
F-60947 Adult Day Care Initial Certification Checklist
F-00311 Nursing Home MDS 3.0 Section Q Referral
F-01942A LTC FS - Diagnosis Verification Letter
F-00193 Pediatric Referral / Communication Wisconsin WIC Program
F-47484 Pre-Review Questionnaire and Application Checklist
F-01622 OARS Records Checklist
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women
F-10154 Statement of Identity for Children Under 18 Years of Age
F-40104 WIC Retail Vendor Annual Food Sales Survey
F-01206A IRIS One-Time Expense Vendor Bid Comparison
F-00052B Cares Data Access and Use Agreement / Designation of Cares Security and Data Exchange Coordinator
F-00100 State Vital Records Birth Certificate Request Letter
F-22491AL Consumer Survey – OBVI (Large Print)
F-00905 Tuberculosis Disease - Initial Medication Request
F-25614 Conditional Release Rules and Conditions
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral
F-21231 County Agency Contacts Regarding Children at MMHI / WMHI
F-80462 Capital Asset Summary
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit

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Last Revised: May 22, 2018