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-00777 MAPT Vendor Related Allocation Formula
F-11289 HealthCheck County Outreach Case Management Plan for County
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-02074 Medicare Other Coverage Discrepancy Report
F-02012 Fluoride Supplement Program Annual Report
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report
F-01899 Central Line-Associated Bloodstream Infection (CLABSI)
F-60367 Community Advisory Committee Documentation
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa
F-47128 Emergency Medical Technician - Basic Training Permit Application (PDF, 711 KB)
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers
F-10147 Wisconsin Veterans Home at King - Medicaid Review
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC)
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service
F-01312 IRIS Provider Application
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-00041 Asbestos Project Notification
F-01588 Application for Available Beds
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-40063 TEFAP / CSFP Commodities Complaint
F-01220 WISEWOMAN Healthy Lifestyle Assessment
F-22637 Interagency Notification -Termination of Community Waiver Participation
F-80460 Account Disclosure Report - Page 1 / Voucher Listing - Page 2
F-01205G IRIS Participant Education: Notices of Action and Appeals
F-21059 Variance Request for Institutional Respite
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster
F-16038 Administrative Disqualification Hearing Notice
F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model
F-00657 Military Training Verification
F-02106 Adult Day Care Center
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers
F-62608 Request for Use of Medical Restraints
F-01769 TEFAP Soup Kitchen Self-Assessment
F-62274A Personal Care Agency Consent for Home Visit
F-13149 HIPAA Privacy Accounting Request
F-47463D Emergency Medical Techician (EMT) - Intermediate Operational Plan Components (PDF, 26 KB)
F-11130 Federally Qualified Health Center Interim Report
F-45021 Generally Licensed Device Inspection by Mail
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2)
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information
F-00114 EMS Service Director License Proxy for Individuals
F-01668 Consent for Participation in Veterans Outreach and Recovery Program (VORP)
F-00004B Health and Employment Counseling - I Have Reached Employment
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter

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Last Revised: July 28, 2017