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 ascending
F-02425 Wisconsin Alzheimer’s Family Caregiver Support Program (AFCSP) Home-Delivered Meals Donation Authorization DPH
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter DMS
F-44016 Asbestos Occupant Protection Plan DPH
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-10144 Wisconsin Life Insurance Inquiry DMS
F-01204E Letter - IRIS Program Notice of Action - Functional Eligibility DMS
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet OS
F-40074 Annual Physical Activity Record DPH
F-02118 Authorized Signer Designation for Access to PPS and FSIA DMS
F-80921 Invoice Request (PRINT ON BUFF PAPER) DES
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-01942C LTC FS - Release of Information Authorization DMS
F-02595 Request for Approval: Youth Crisis Stabilization Facilities (YCSF) Certification Application DCTS
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH
F-01314 IRIS Program Employment Checklist DMS
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids DMS
F-22564 Authorization for Retroactive Caretaker Supplement (CTS) DMS
F-62652 Home Health Agency Licensure Survey Home Visit Guide DQA
F-00565 County Performance Plan (CPP) DMS
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-01829 Authorization to Receive and Disclose Information - AIDS/HIV Drug Assistance and Insurance Assistance Programs DPH
F-62320 Hospice Survey Information DQA
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care DCTS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-01649 Coverdell Stroke Champion Partner Agreement DPH
F-00236A Request for a State Fair Hearing - ADRC DPH
F-02460 OBVI Bold Lined Paper DPH
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS
F-00989M Justification for Services Provided in Locations Other than Natural Environments (IFSP) DMS
F-01200 IRIS Program Cost Share Repayment Agreement DMS
F-20933 Court Order for Assessment DCTS
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting DMS
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases DPH
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request DQA
F-00576A Tribal Aging and Disability Resource Specialist (TADRS) Annual Budget DPH
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-00040 Asbestos Course Accreditation - Renewal DPH
F-01229 WISEWOMAN Provider Assurances and Training Checklist DPH
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-80477 Canteen Operations Statement of Revenues / Expenses and Fund Equity Changes - GAAP Basis DES
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DMS
F-22018 HSRS Long-Term Support Module - Module Type A DMS
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS
F-62594 Notice of Substantial Change Feeding Assistant Training Program DQA
F-02573 Prior Authorization Drug Attachment for Wakix DMS
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 DQA
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS

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Last Revised: March 26, 2019