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-02108C Adult Family Home – New Provider Licensure Application DQA
F-00805 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-11022 Rural Health Clinic Statistical Data DMS
F-01205J IRIS Participant Education: Self-Directed Personal Care DMS
F-44010 Lead-Free / Lead-Safe Property Registry, Training Course, Class and Roster Database Access Application DPH
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-00538 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 DQA
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter DMS
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-02265 Latent Tuberculosis Infection (LTBI) Confidential Case Report DPH
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-01204A Letter – IRIS Program Notice of Action – Denial DMS
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate DMS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-62674A Model Balance Sheet DQA
F-02715 ADRC Client Tracking System Waiver Request DPH
F-01442J IRIS Program Disenrollment Letter - Mismanagement DMS
F-02634A Adult Family Home (AFH) Initial Survey Checklist DQA
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-11136 Personal Care Addendum DMS
F-62680 Home Health Agency (HHA): Clinical Record Review (State Only) DQA
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-02634B Community-Based Residential Facility (CBRF) Initial Survey Checklist DQA
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-16076 FoodShare Six-Month Report and Instructions DMS
F-01146 Wisconsin Chronic Disease Program Provider Data Sheet DMS
F-62370 Significant Change in Health Screening Instrument Model Form DQA
F-13149 HIPAA Privacy Accounting Request DMS
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter DMS
F-02558 Family Care Member County Notification DMS
F-00987A EMS Service Operational Plan Advanced Skills Addendum (Intermediate) DPH
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording OS
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers DPH
F-02476A Nurse Aide Federal Employment Eligibility Renewal: Employee Roster DQA
F-00657 Nurse Aide Training Program: Military Training Verification DQA
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-00989P Individualized Family Service Plan Team Signature (IFSP) DMS
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine DPH
F-02324 Wisconsin’s American Sign Language Interpreter, SSP and CART Directory Sign-Up and/or Change Request DPH
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting DMS
F-02112 2017 Community Support Program (CSP) Survey Worksheet DCTS
F-10097 Medicaid Income Allocation Notice DMS
F-40019 Affirmation of Identity, Residency, and/or Income DPH

Pages

Last Revised: March 26, 2019