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-47125 Emergency Medical Technician - Intermediate Training Permit Application (PDF, 233 KB) English
F-01579 Wisconsin eWIC Cash Register System Survey English
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) English
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels English
F-10146 Employer Verification of Earnings English
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC) (PDF, 291 KB) English
F-01205G IRIS Participant Education: Notices of Action and Appeals English
F-01546 IRIS Consultant Agency (ICA) Biography English
F-44771AA Medicaid Targeted Case Management Face Sheet - Childhood Lead Poisoning English
F-40062 The Emergency Food Assistance Program TEFAP and CSFP Commodity Loss Report English
F-01218 WISEWOMAN Client Consent English
F-00262 Personal Care Agency Application Materials Checklist English
F-22637 Interagency Notification -Termination of Community Waiver Participation (PDF, 41 KB) English
F-80459 Client Account Balance Report English
F-21059 Variance Request for Institutional Respite English
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement English
F-01108 Federally Qualified Health Center Terms of Reimbursement (PDF, 42 KB) English
F-16038 Administrative Disqualification Hearing Notice (PDF, 101 KB) English
F-00950 CMS 10003-NDMCP, Notice of Denial of Medical Coverage English
F-00660A Client Rights Office Consult Question English
F-00519 CSAS Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 English
F-00909 Personal Care Consumer Survey English
F-02052 Asbestos Abatement Project Log (PDF, 87 KB) English
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s) English
F-62607 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan English
F-01766 TEFAP Shelter Review English
F-62236 Hospice Clinical Record Review English
F-44212 School Report to the District Attorney (PDF, 42 KB) English
F-47463C Emergency Medical Techician (EMT) - Intermediate Technician Operational Plan Components (PDF, 721 KB) English
F-11129B-H Wisconsin Medicaid - Federally Qualified Health Center Cost Report Forms English
F-45020 Cumulative Occupational Exposure History (PDF, 149 KB) English
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) English
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years (PDF, 27 KB) English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information English
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections English
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter English
F-44444 WIC Vendor Supply Order English
F-01468A IRIS Program Start Date Letter – Transferring Participant English
F-42016 Authorization for Release of Confidential HIV Test Results English
F-01389 ROSI Adult Satisfaction Survey English
F-29322 Uniform Cost Sharing Plan - COP Cost-Share Worksheet 3 English
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer English
F-01275 IRIS Provider Board Member Disclosure English
F-22468 Application for Services Office for the Blind and Visually Impaired English
F-01199 Wisconsin Medicaid - Optional School-Based Services Activity Medication Administration English
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization English
F-01067 HealthCheck Your Child's Speech and Hearing English
F-00893 Affidavit of No Social Security Number - EMS Professional Licensing English
F-00615A Change Project Summary and Instructions English
F-82003 Denial of Researcher Access To Health Care Records (PDF 14 KB) English

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Last Revised: July 28, 2017