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-80190 Travel Reimbursement Request Non-State Employee DES
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet DMS
F-01767 TEFAP Shelter Self-Assessment Tool DPH
F-01206B IRIS One-Time Expense Request - Ramp DMS
F-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request DQA
F-02314E Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation for Annual Employee Screening DPH
F-16022 Social Security Number Referral DMS
F-01689 Participant-Hired Worker 40-Hour Health And Safety Assurance Exception Request – IRIS Program DMS
F-62096A DQA Authority for Obtaining Provider Records Without Written Release DQA
F-02495 Vaccine for Adults (VFA) Provider Agreement DPH
F-01234 Explanation of Medical Benefits DMS
F-02432 IRIS Program HIPAA Breach and Unauthorized Disclosure Reporting DMS
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTS DMS
F-11048 Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS
F-01486 IRIS Consultant Biography DMS
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable DMS
F-10161 Statement of Citizenship and/or Identity DMS
F-01402 Test Your Knowledge About Trauma-Informed Care DCTS
F-00472 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 DQA
F-40117 Abortion Information Provision Certification DPH
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-82006 Employment Application and Resume DES
F-22687 Collaborative Systems of Care (CSOC) Plan of Care DCTS
F-02035 Aging/ADRC Integration Funding Request Application DPH
F-62687 Nurse Aide Training Program - Trainer Application DQA
F-02616 Supervised Release (SR) Client Vehicle Purchase Request DCTS
F-01894 Vendor Overpayment Findings Letter DMS
F-02538 Children’s Long-Term Support Waiver Program—Outlier Rate Request DMS
F-00335 Voluntary Agreement for Crisis Stabilization Services DCTS
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-00044 User Agreement for System Access DES
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo DMS
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night DQA
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request DMS
F-01624 OARS Alternative to Revocation (ATR) Referral DCTS
F-01062 HealthCheck Adolescent Review DMS
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist DQA
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-01275A IRIS Provider Executive Staff Disclosure DMS
F-00855 Medication Therapy Management Case Management Software Requirements DMS
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS

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Last Revised: March 26, 2019