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-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs
F-01391B Mental Health Statistics Improvement Program (MHSIP) Family Data Workbook
F-22638 Notification of Waiver Program Termination
F-21063 Exception to Care Management / Support and Service Coordination Contact Requirements
F-16039 Waiver of Administrative Disqualification Hearing
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-00787 Prior Authorization - Requirement Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-82018C Work Time Absence Record
F-02157 Nurse Aide Training Program – Application for Approval Checklist
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA)
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting
F-16050 Agency Position on the State Quality Control (QC) Finding
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral
F-00565 County Performance Plan (CPP)
F-82021 Researcher's Request for Confidential Records or Human Subjects Research
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement
F-00417 AODA Prevention Services Recertification Application - DHS 75.04
F-02021 IRIS - Certified Public Accountant (CPA) Audit Checklist
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation
F-62500 Fire Report for Adult Family Homes, Community-Based Residential Facilities, FDDs, Hospitals, and Nursing Homes
F-13151 HIPAA Privacy Amendment Request
F-62028 Report of Hours Worked - Nurse Aide / Night
F-11129B-H Federally Qualified Health Center Cost Report Forms
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1)
F-10115 BadgerCare Plus / Medicaid Health Insurance Information
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire
F-01332 Predispositional Investigation Report (PDI)
F-01749 Prior Authorization / Preferred Drug List (PA/PDL) for Hypoglycemics, Insulin – Long-Acting
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification
F-01206B IRIS One-Time Expense Request - Ramp
F-01649 Coverdell Stroke Champion Partner Agreement
F-00047 Designated Asbestos Coordinator
F-44621 WIC Stock Price Survey
F-00989i Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP)
F-42023 Vaccine Celsius Temperature Log
F-01459 Tuberculosis (TB) Program Dispensary Pre-Authorization for Non-Routine TB Services
F-22491 Consumer Report and Survey - OBVI
F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination
F-00681 Partnership - Three (3) Managed Care Organization (MCO) Options
F-01359 Historical Earnings Verification Request
F-02242 Hepatitis A High-Risk Occupations Questionnaire
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03
F-80911 Limited Term Employment (LTE) or Project Employment Application
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program
F-62652A Personal Care Agency Home Visit Guide
F-16022 Social Security Number Referral


Last Revised: May 22, 2018