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-60309 Self-Supervision Evaluation and Waiver Request
F-11019 Prior Authorization / Physician Otological Report (PA/POR)
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope
F-10114 Medicaid Disability Redetermination Report
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment
F-01751 Request for IMD Rebalancing Initiative Funding – Summary
F-01542 Notification of Required Drug Testing
F-00989H Child/Family Outcome (IFSP)
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB)
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility
F-25206 Petition for Capias
F-01229 WISEWOMAN Provider Assurances and Training Checklist
F-01182 Declaration of Supervision for Nonbilling Providers
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-16022 Social Security Number Referral
F-00787 Prior Authorization - Requirement Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-02385 Vaccine Accountability -Vaccine Preventable Disease: Tetanus
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-80751 Non-County Resident Proceedings Cost Certification
F-62418 Adult Day Care Initial Certification Application
F-62610 Nurse Aide Training Program Primary Instructor Application
F-01454F IRIS Program Withdrawal Letter - Death
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions
F-62274A Personal Care Agency Consent for Home Visit
F-11067 Record of Actual Daily Oxygen Use
F-47463C Intermediate Technician Operational Plan Components
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service
F-10080 SeniorCare Authorization of Representative
F-01901 Surgical Site Infection (SSI)
F-01622 OARS Records Checklist
F-45007 Certificate of Disposition of Materials
F-01579 Wisconsin eWIC Cash Register System Survey
F-44003 Lead-Safe Renovator Application
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program
F-40072 8 Week Activity Log
F-01206B IRIS One-Time Expense Request - Ramp
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-00052 Aging and Disability Resource Center (ADRC) Application
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center
F-01902 Symptomatic Urinary Tract Infection (SUTI)
F-01205P IRIS Participant Education: Background Check Process
F-45008 Application for Radioactive Material License for Medical Use
F-01586 Medical Stockpile Access Request

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Last Revised: May 22, 2018