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-45021 Generally Licensed Device Inspection by Mail DPH
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS
F-00727 Typical Hearing Developmental Milestones DMS
F-11042 Prior Authorization Amendment Request DMS
F-00603a PPS Core Deskcard DES
F-01389B MHSIP Family Satisfaction Survey DCTS
F-10150B Your Rights and Responsibilities for FoodShare DMS
F-02167 Program Participation System (PPS) PORTAL Report Feedback DCTS
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11 DQA
F-40096 eWIC Program Repayment Agreement DPH
F-80983 Civil Rights Complaint DES
F01454G IRIS Program Withdrawal Letter - Cancelled DMS
F-22640 Application for Wisconsin Interpreting and Transliterating Assessment (WITA) DPH
F-62658 Home Health Agency Program Evaluation Review Worksheet DHS 133.07(3) DQA
F-00330 Request for Replacement FoodShare Benefits DMS
F-01293 Participant Fiscal Employer Agent (FEA) Selection DMS
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-20582 Medicaid – Katie Beckett Program Application DMS
F-62373 Resident Evacuation Assessment DQA
F-02535 Nursing Home: Notice of Change for Administrator of Director of Nursing DQA
F-00040 Asbestos Course Accreditation - Renewal DPH
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement DMS
F-01670 Wisconsin AIDS Drug Assistance Program (ADAP) Exception Report DPH
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-02461 Tuberculosis (TB) Treatment Assistance Program - Special Request DPH
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter DMS
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member DMS
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-44000 Tuberculosis Disease Initial Request for Medication DPH
F-00615A Change Project Summary and Instructions DPH
F-01411 Education - Medication Summary - Part B DPH
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application DQA
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-80762 Store Inventory Reconciliation Worksheet DES
F-01954 Wisconsin EMS Training Record NCCP AEMT Refresher Requirements DPH
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-22491 Consumer Report and Survey - OBVI DPH
F-62610 Nurse Aide Training Program Primary Instructor Application DQA
F-02592 Rapid Test and Controls Inventory Log DPH
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist DQA
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH

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Last Revised: March 26, 2019