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-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids
F-00052B Cares Data Access and Use Agreement / Designation of Cares Security and Data Exchange Coordinator
F-01210 IRIS Budget Amendment Request
F-01593A Civil Money Penality (CMP) Funded Project Report
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption
F-44192 Child Care Immunization Record
F-22491AL Consumer Survey – OBVI (Large Print)
F-00905 Tuberculosis Disease - Initial Medication Request
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements
F-00987C EMS Service Operational Plan Advanced Skills Addendum (First Responder)
F-02424 National Fatality Review Case Reporting System: Access Request and Confidentiality Statement
F-25614 Conditional Release Rules and Conditions
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard
F-80462 Capital Asset Summary
F-00476 CARES Automated Systems Access Request
F-16029 FoodShare Wisconsin Repayment Agreement
F-02068 Request to Establish a Children's COP Risk Reserve
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services
F-13066 Claim Refund
F-62165 Report of Hours Worked - Licensed Practical Nurse / Evening
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs
F-00161 Caregiver Misconduct Reporting Requirements Worksheet
F-01997 Children's Community Options Reconciliation Packet
F-00024 HSRS Core Summary Report
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-01885 Requesting State Trauma Registry Access
F-10190 Medicaid Issuer of Annuity - Notice of Obligation
F-01627 OARS Provider Case Manager Checklist
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels
F-10098 Medicaid Member Asset Allocation Notice
F-01205J IRIS Participant Education: Self-Directed Personal Care
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC)
F-01346 Behavior Monitoring Record-Model
F-01421 WISEWOMAN Monthly Reporting for Direct Services
F-01302 Weekly Driver's Vehicle Inspection Report
F-01205 IRIS Participant Education: Self-Direction Responsibilities
F-01068G General Pediatric Clinic - 15 Month Visit
F-40092 Physical Activity Zone
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program
F-22637 Interagency Notification -Termination of Community Waiver Participation
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research
F-00567 Emergency Medical Services Complaint
F-20818 Certification for SSI-E Exceptional Expense Supplement
F-02086 Histoplasmosis Case Worksheet
F-00417 AODA Prevention Services Recertification Application - DHS 75.04

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Last Revised: May 22, 2018