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
F-01270 Comprehensive Community Services Non-Traditional Approval
F-22468 Application for Services Office for the Blind and Visually Impaired
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age
F-00889 Designation of Confidential and Proprietary Information - Managed LTC Business Plan
F-00615A Change Project Summary and Instructions
F-82009 Confidential Information Release Authorization - Generic 
F-02102 Getting Ready for the On-Site Visit - Birth to 3 Program
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-20891 Intoxicated Driver Program Supplemental Funding Request
F-62519 Hospice Regulatory Guide – Comparison of State Code and Federal Conditions of Participation
F-62069A Personal Care Agency Complaint Report
F-00596 PPS Mental Health Module
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication
F-00334 Money Follows the Person (MFP) - Participant Reporting
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities
F-01937 Wisconsin EMS Paramedic Training Record - Paramedic Refresher Requirements
F-42014 Acuity Index
F-01542 Notification of Required Drug Testing
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required)
F-00989L Summary of Services (IFSP)
F-44024A WIC Prescriptions / Clinical Data - Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse
F-40104 WIC Retail Vendor Annual Food Sales Survey
F-01348B Itemized Method, Administration and Support Staff Worksheet
F-00059 Outpatient Mental Health Clinic Application - DHS 35
F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application
F-01164 Consent for Sterilization
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-01413 Post-Assessment Questionnaire
F-01729 Nonprobate Asset / Property Disclosure
F-80883 CARS Contract Adjustment - Extensions and Moves
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet
F-62657 Home Health Agency Contract Review Worksheet
F-20445 Individual Service Plan - Medicaid Waivers
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request
F-00777 MAPT Vendor Related Allocation Formula
F-11289 HealthCheck County Outreach Case Management Plan for County
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-02074 Medicare Other Coverage Discrepancy Report
F-02012 Fluoride Supplement Program Annual Report
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report
F-01899 Central Line-Associated Bloodstream Infection (CLABSI)
F-60367 Community Advisory Committee Documentation
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa
F-47128 Emergency Medical Technician - Basic Training Permit Application

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Last Revised: July 28, 2017