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 Division Other Locationsort descending
F-21336 Consent for Exchange of Information with Local Educational Agency DMS
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member DMS
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-00989J Transition Plan - Turning 3 Years Old (IFSP) DMS
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) DQA
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) DMS
F-22550 Birth to 3 Program Parental Cost Share DMS
F-01212 Grievance - IRIS Program DMS
F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus OIG
F-42017 Wisconsin Initial Refugee Health Assessment DPH
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-00046 Family Care Program - Enrollment DPH
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-01218 WISEWOMAN Client Consent DPH
F-02051 Wisconsin Donor Registry Enrollment DPH
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS
F-40303 Early Childhood Caries Prevention Screening DPH
F-02601 Wisconsin 1-2 Bed Adult Family Home (AFH) Application DMS
F-01726 Basic Equipment List for Nurse Aide Training Programs DQA
F-47482 EMT Training Center Certification Application DPH
F-02106C Adult Day Care Center – New Provider Certification Application DQA
F-01586 Medical Stockpile Access Request DPH
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals DCTS
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-62648A Personal Care Agency Sample Selection DQA
F-02400B Client Transfer: Labels DQA
F-01016 ForwardHealth Provider Suggestion DMS
F-62288 Care Level Determination Worksheet DQA
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-16026 Prosecution Diversion Agreement DMS
F-01545 IRIS Fiscal Employer Agent (FEA) Biography DMS
F-01999B Senior Companion Program: State Match Funding Application DPH
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-80142 Collections Delegation Application DES
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-02031 Initial Application – Individual Lead Disciplines DPH
F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease DMS
F-82009F Confidential Information Release Authorization: WISHIN DCTS
F-01938 Wisconsin EMS Paramedic Training Record - NCCP Paramedic Refresher Requirements DPH
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-62579 Post Survey Questionnaire DQA
F-00321 OBVI Initial Interview Assessment DPH
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination DPH

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Last Revised: March 26, 2019