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-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-01206B IRIS One-Time Expense Request - Ramp DMS
F-01700 Exception-to-Policy Request (AIDS/HIV) DPH
F-16022 Social Security Number Referral DMS
F-62092 Hospital Certificate of Approval Application DQA
F-02502 Vaccine for Adults (VFA) Community Outreach DPH
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup DMS
F-00388 County Birth to 3 Fiscal Reconciliation Report DMS
F-00315D Written Prior Notice - Additional Assessment Recommended DMS
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-00926 Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTS DMS
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH
F-11048 Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS
F-01068L General Pediatric Clinic - Teenager Visit DMS
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS
F-00926A Request for Use of Medical Restraints – CLTS DMS
F-01486 IRIS Consultant Biography DMS
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-01402 Test Your Knowledge About Trauma-Informed Care DCTS
F-10162 Verification of Veterans Benefits DMS
F-40117 Abortion Information Provision Certification DPH
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-82006 Employment Application and Resume DES
F-05260 Letter of Non-Marriage Application DPH
F-02035 Aging/ADRC Integration Funding Request Application DPH
F-22688 Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide DCTS
F-62687 Nurse Aide Training Program - Trainer Application DQA
F-01894 Vendor Overpayment Findings Letter DMS
F-00154 Wisconsin Consultative Examination Inquiry DMS
F-02541 Wisconsin Birth Defects Condition Nomination DPH
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months DMS
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-62442 Report of Hours Worked - Other Direct Care Nurse Aide / Night DQA
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo DMS
F-01624 OARS Alternative to Revocation (ATR) Referral DCTS
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-60820 Corporate Guardianship Program Status Application, Instructions and Checklist DQA
F-02474 Active Tuberculosis (TB) Disease Follow-up Report DPH
F-01063 HealthCheck Family History DMS
F-01275A IRIS Provider Executive Staff Disclosure DMS
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS

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Last Revised: March 26, 2019