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-40096 eWIC Program Repayment Agreement
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-25213 Admission to Caseload - Mental Health
F-01220 WISEWOMAN Healthy Lifestyle Assessment
F-01205D IRIS Participant Education: Program Integrity - Fraud Prevention
F-21189 Rights of Detention
F-01068K General Pediatric Clinic - Elementary School Visit
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08
F-20009 Complaint Report
F-01310 IRIS Program Conflict of Interest Disclosure – Provider
F-02110 Residential Care Apartment Complex (RCAC)
F-00154 Wisconsin Consultative Examination Inquiry
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member
F-80459 Client Account Balance Report
F-44215 Child Care Center Report to the District Attorney
F-62588 Feeding Assistant Training Program Application
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request
F-62158 Living Unit Direct Care Staff Report - Night Shift
F-11240 Case Management Provider Information
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance
F-00315D Written Prior Notice - Additional Assessment Recommended
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs
F-00044 User Agreement for System Access
F-01621 Smoking Cessation Data Collection
F-10108 Medicaid Manual Notice for Cost of Care Contribution
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter
F-22564 Authorization for Retroactive Caretaker Supplement (CTS)
F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo
F-01062 HealthCheck Adolescent Review
F-00385 Nurse Aide Training - Student Waiver Request
F-20933 Court Order for Assessment
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-82009 Confidential Information Release Authorization - Generic 
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request
F-00685 Statement of Tribal Affiliation
F-20985 Participant Rights and Responsibilities Notification
F-62696 Student Nurse / Graduate Nurse Verification
F-16029 FoodShare Wisconsin Repayment Agreement
F-13066 Claim Refund
F-00576A Tribal Aging and Disability Resource Specialist (TADRC) Annual Budget
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-10190 Medicaid Issuer of Annuity - Notice of Obligation
F-01264 Service Fund Application for Reimbursement
F-02035 Aging/ADRC Integration Funding Request Application
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-62024 Report of Hours Worked - Nurse Aide / Day

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Last Revised: May 22, 2018