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-02614 Fraud Prevention and Investigation Program (FPIP) Fraud Year Contact Information OIG
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter DMS
F-00330 Request for Replacement FoodShare Benefits DMS
F-01293 Participant Fiscal Employer Agent (FEA) Selection DMS
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS
F-00171 Lead Company Application DPH
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report DQA
F-00041 Asbestos Project Notification DPH
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement DMS
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-01210B Budget Amendment Annual Verification (BAAV) Request DMS
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-02470 IRIS Noncompliance Statement and Corrective Action Plan DMS
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter DMS
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-02371 Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists DMS
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member DMS
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-02258 Minority Health Advisory Committee Application DPH
F-01413 Post-Assessment Questionnaire DPH
F-60945 Adult Family Home Initial Licensure Application DQA
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS
F-80783A Family Financial Questionnaire - County Use DES
F-22491 Consumer Report and Survey - OBVI DPH
F-01955 Wisconsin EMS Training Record Critical Care Paramedic Refresher Record DPH
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-00565 County Performance Plan (CPP) DMS
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application DMS
F-40062 TEFAP / CSFP Commodity Loss Report DPH
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care DCTS
F-80857 Special CARS Run request DES
F-22538 Consent to Photograph or Record and Use of Photographs/Recordings DCTS
F-02011 Fluoride Mouth Rinse Program Annual Report DPH
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS
F-62641 Hospice Inpatient Symptom Management and Respite Contract or Agreement Review DQA
F-02592 Rapid Test and Controls Inventory Log DPH
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice DMS
F-16050 Agency Position on the State Quality Control (QC) Finding DMS
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter DMS
F-62281 Care Level Change Notice DQA
F-02106A Adult Day Care Center – Established Provider Certification Application DQA
F-00004 Health and Employment Counseling Application DMS
F-01153 Breast Pump Order DMS
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS

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Last Revised: March 26, 2019