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-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-01486 IRIS Consultant Biography DMS
F-00101 Authorization to Request Birth Records DMS
F-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-10162 Verification of Veterans Benefits DMS
F-01402 Test Your Knowledge About Trauma-Informed Care DCTS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-40117 Abortion Information Provision Certification DPH
F-05260 Letter of Non-Marriage Application DPH
F-82006 Employment Application and Resume DES
F-02035 Aging/ADRC Integration Funding Request Application DPH
F-22688 Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide DCTS
F-62687 Nurse Aide Training Program - Trainer Application DQA
F-01894 Vendor Overpayment Findings Letter DMS
F-02541 Wisconsin Birth Defects Condition Nomination DPH
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years DMS
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo DMS
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night DQA
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-01624 OARS Alternative to Revocation (ATR) Referral DCTS
F-02474 Active Tuberculosis (TB) Disease Follow-up Report DPH
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-01063 HealthCheck Family History DMS
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist DQA
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-01275A IRIS Provider Executive Staff Disclosure DMS
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process DMS
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers DPH
F-00568 EMS Board Sub-Committee Appointment Application DPH
F-44005 Visual Inspection of Registered Lead-Safe Property DPH
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center DPH
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement DQA
F-00219 Self-Employment Income Report: Farm Business DMS
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-80882 CARS Contract Variance Correction DES
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS
F-02605 Home and Community-Based Services (HCBS) On-Site Review Visit: Nonresidential Settings Entrance Handout DMS
F-01256 FoodShare Employment and Training (FSET) - Discuss FSET Participation DMS
F-62644 Drug Repository Program Donation, Transfer, and Destruction Record DQA
F-44212 School Report to the District Attorney DPH
F-02108D Adult Family Home – New Provider Licensure Application Checklist DQA


Last Revised: March 26, 2019