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 Language
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) English
F-01228 WISEWOMAN Healthy Behavior Intervention Change Assessment English
F-02191 CLTS County Wait List Transition Plan English
F-25206 Petition for Capias English
F-80761 Contingent Account Activity Report English
F-00553 Professional & Occupational License Application & Affidavit English
F-21150A Adult Protective Services (APS) Investigation Transfer - Model English
F-62648A Personal Care Agency Sample Selection English
F-00407 Financial Records Request (PDF, 28 KB) English
F-00232 Notice of Action - MCOs English
F-20389 DCTS Program Performance Report English
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Community Recovery Services Provider Entities English
F-10189 Undue Hardship Bed Hold Notice English
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint (PDF, 168 KB) English
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine English
F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-DependentLife-Support Addendum English
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report English
F-01997 Children's Community Options Reconciliation Packet English
F-62320 Hospice Survey Information English
F-01885 Requesting State Trauma Registry Access English
F-47482 Emergency Medical Service Training Center Certification Application (PDF, 84 KB) English
F-01354 OARS Individual Service Plan (ISP) English
F-01512 Occupational Therapy Terms of Reimbursement (PDF, 42 KB) English
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment English
F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers English
F-01016 ForwardHealth Provider Suggestion (PDF, 84 KB) English
F-01572 Ice Arena Log of Pollutant Exceedance English
F-01319B IRIS Denial of Enrollment Request English
F-83263 Rehabilitation Review Application and Instructions (PDF, 61 KB) English
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP) English
F-00520 CSAS Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06 English
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program English
F-20980 Assessment / Supplement to the Long Term Care Functional Screen English
F-16030 FoodShare Wisconsin Under/Overissuance Worksheet and Overpayment Calculator English
F-02086 Histoplasmosis Case Worksheet English
F-80122 Journal Voucher English
F-02047 IRIS Financial Reporting Template English
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors (PDF, 21 KB) English
F-00521 CSAS Prevention Service Initial Certification Application - DHS 75.04 English
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member English
F-20985 Participant Rights and Responsibilities Notification English
F-16031 Student Aid and Expense Worksheet (PDF, 256 KB) English
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals English
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer English
F-62590 Post Onsite Review Questionnaire - Nurse Aide Training Programs English
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years (PDF, 28 KB) English
F-01748 Tuberculosis (TB) Risk Assessment Questionnaire Screen English
F-62166 Report of Hours Worked - Licensed Practical Nurse / Night English
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) English
F-00180A WI Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Traditional Providers English

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Last Revised: July 28, 2017