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.
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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 Location |
|---|---|---|---|
| F-01428 | Birth to 3 Program Invitation to Individualized Family Service Plan Meeting (IFSP) | DMS | None |
| F-01430 | Prior Authorization Drug Attachment for Xyrem | DMS | None |
| F-01438 | Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) | DMS | None |
| F-01439 | Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) | DMS | None |
| F-01442 | IRIS Disenrollment Letter - Death | DMS | None |
| F-01442A | IRIS Program Disenrollment Letter – Financial Eligibility | DMS | None |
| F-01442B | IRIS Program Disenrollment Letter – Functional Eligibility | DMS | None |
| F-01442C | IRIS Program Disenrollment Letter – No Contact | DMS | None |
| F-01442D | IRIS Program Disenrollment Letter – Incomplete Functional Screen | DMS | None |
| F-01442E | IRIS Program Disenrollment Letter – Ineligible Setting | DMS | None |
| F-01442F | IRIS Program Disenrollment Letter – Missing Signature Page | DMS | None |
| F-01442G | IRIS Program Disenrollment Letter – Non-Spending | DMS | None |
| F-01442H | IRIS Program Disenrollment Letter – Voluntary | DMS | None |
| F-01442i | IRIS Program Disenrollment Letter - Cancelled | DMS | None |
| F-01442J | IRIS Program Disenrollment Letter - Mismanagement | DMS | None |
| F-01442K | IRIS Program Disenrollment Letter - Policy Noncompliance | DMS | None |
| F-01445 | Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) | DMS | None |
| F-01446 | Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) | DMS | None |
| F-01454 | IRIS Program Withdrawal Letter – No Progress | DMS | None |
| F-01454A | IRIS Program Withdrawal Letter – Financial or Functional Eligibility | DMS | None |
| F-01454B | IRIS Program Withdrawal Letter – Health and Safety | DMS | None |
| F-01454C | IRIS Program Withdrawal Letter – No Contact | DMS | None |
| F-01454D | IRIS Program Withdrawal Letter – Non Eligible Setting | DMS | None |
| F-01454E | IRIS Program Withdrawal Letter – Voluntary | DMS | None |
| F-01454F | IRIS Program Withdrawal Letter - Death | DMS | None |
| F-01468 | IRIS Program Start Date Letter – New Participant | DMS | None |
| F-01468A | IRIS Program Start Date Letter – Transferring Participant | DMS | None |
| F-01477 | Wisconsin Medicaid Program Nursing Home Cost Report Website User Request | DMS | None |
| F-01481 | Marriage Record Amendment Request Officiant Affidavit | DPH | None |
| F-01486 | IRIS Consultant Biography | DMS | None |
| F-01542 | Notification of Required Drug Testing | DMS | None |
| F-01545 | IRIS Fiscal Employer Agent (FEA) Biography | DMS | None |
| F-01546 | IRIS Consultant Agency (ICA) Biography | DMS | None |
| F-01549 | IRIS Certification Designation of Confidential and Proprietary Information | DMS | None |
| F-01555 | Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility | DMS | None |
| F-01555A | Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility | DMS | None |
| F-01556 | Medicaid Cost Share Letter - Initial | DMS | None |
| F-01556A | IRIS Program First Delinquent Medicaid Cost Share Payment Letter | DMS | None |
| F-01556B | IRIS Program Second Delinquent Medicaid Cost Share Payment Letter | DMS | None |
| F-01556BB | IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter | DMS | None |
| F-01556C | IRIS Program Cost Share Repayment Plan Letter | DMS | None |
| F-01556D | IRIS Program Letter – Disenrollment | DMS | None |
| F-01556E | IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer | DMS | None |
| F-01558 | Risk Agreement – IRIS Program | DMS | None |
| F-01563 | IRIS Consultant Agency (ICA) Provider Change Letter | DMS | None |
| F-01564 | Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation | DMS | None |
| F-01565 | Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume | DMS | None |
| F-01566 | IRIS Self-Directed Personal Care (SDPC) – My Cares | DMS | None |
| F-01566A | IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care | DMS | None |
| F-01567 | Long-Term Care Insurance Policy – Assignment of Benefits | DMS | None |
Pages
Last Revised: March 26, 2019
