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-01618 Client Services Agreement for Medicare Counseling DPH
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-00950A Notice of Denial of Medical Coverage – PACE DMS
F-00889 Designation of Confidential and Proprietary Information - Managed LTC Business Plan DMS
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS
F-44017 Asbestos Application - Individual DPH
F-20934 Court Ordered Assessment and Plan Report DCTS
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS
F-00905 Tuberculosis Infection (LTBI) Initial Request for Medication DPH
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS
F-40073 Monthly Physical Activity Sheet DPH
F-02242 Hepatitis A High-Risk Occupations Questionnaire DPH
F-82064 Background Information Disclosure (BID) DQA
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA
F-22553A Free In-Service or Educational Training Request DPH
F-02066 Abbreviated Denial Corrective Action Plan (CAP) Wisconsin WIC Program DPH
F-01261 Fraud Statement - IRIS Program DMS
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-20009 Complaint Report DCTS
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review DPH
F-62430 Community Based Residential Facility (CBRF) Residents' Rights Complaint Report DQA
F-02588 Financial Exploitation Tracking for Counties DPH
F-01700 Exception-to-Policy Request (AIDS/HIV) DPH
F-02109B CBRF – Established Provider Licensure Application Checklist DQA
F-01165 Newborn Report DMS
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS
F-47479 Trauma Care Facility Classification Application DPH
F-11129B-H Federally Qualified Health Center Cost Report Forms OIG
F-01572 Ice Arena Log of Pollutant Exceedance DPH
F-00704 Prior Authorization - Committee Public Testimony Registration DMS
F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-00041 Asbestos Project Notification DPH
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-00727 Typical Hearing Developmental Milestones DMS
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 DQA
F-43013 Diabetes Medical Management Plan DPH
F-62546 Corporate Guardianship Program Annual Report DQA
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS
F-01207A IRIS Fiscal / Employer Agent Quality Management Plan Tracking DMS
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-02108 Adult Family Home – Applicant Compliance Statement DQA
F-80900 Receivables Annual Report DES
F-11130 Federally Qualified Health Center Interim Report DMS
F-01573 Log of Ice Arena Air Quality DPH
F-00759 Business Associate Agreement: With Contract DES
F-45007 Certificate of Disposition of Materials DPH


Last Revised: March 26, 2019