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-02124 2016 Comprehensive Community Services (CCS) Program Survey Worksheet English
F-01983 Self-Employment Income Worksheet: Business Capital Gains or Losses (Form 4797) English
F-00020 Drug Addition Review Request English
F-62069 Home Health Agency Complaint Report English
F-00907 OASIS Assessment Deletion Request English
F-02258 Minority Health Advisory Committee Application English
F-82006 Employment Application and Resume English
F-02102 Getting Ready for the On-Site Visit - Birth to 3 Program English
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ) English
F-00021 HealthCheck Referral (PDF, 1.4 MB) English
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation English
F-16021 Student Financial Report (PDF, 194 KB) English
F-62069A Personal Care Agency Complaint Report English
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions (PDF, 126 KB) English
F-00603a PPS Core Deskcard (PDF, 20 KB) English
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services (PDF, 36 KB) English
F-00473 CSAS Intervention Service Recertification Application - DHS 75.16 English
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication English
F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) English
F-01936 EMS Intermediate Training Record - Intermediate Refresher Requirements (PDF, 165 KB) English
F-01708 Case Management Comprehensive Assessment (PDF, 1 MB) English
F-01625 OARS Participant Discharge Summary English
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) English
F-00989K Transition Plan - Other (IFSP) English
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women English
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page English
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse English
F-40104 WIC Retail Vendor Annual Food Sales Survey English
F-01349 Substitute Care Model Quality Performance Standards & Measures (Model) (PDF, 172 KB) English
F-25527 Request for Increased Contract Allocation English
F-01240 IRIS Critical Incident Reconciliation English
F-01168 Wisconsin Medicaid - Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases English
F-01412 Pre-Assessment Questionnaire English
F-16066 FoodShare Wisconsin Income Change Report English
F-80883 CARS Contract Adjustment - Extensions and Moves English
F-21276 DCTS Annual Grant/Contract Application English
F-62657 Home Health Agency Contract Review Worksheet English
F-00171 Lead Company Application English
F-20445A Individual Service Plan - Individual Outcomes English
F-62373 Resident Evacuation Assessment English
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request (PDF, 154 KB) English
F-00785 Outpatient Mental Health Clinic Recertification Application English
F-11296 Wisconsin Medicaid - SMV Transportation Service Informational (PDF, 61 KB) English
F-00553 Professional & Occupational License Application & Affidavit English
F-00407 Financial Records Request (PDF, 28 KB) English
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Community Recovery Services Provider Entities English
F-02012 Fluoride Supplement Program Annual Report English
F-01892 Symptomatic Urinary Tract Infection English
F-60367 Community Advisory Committee Documentation English
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra English

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Last Revised: July 28, 2017