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.
- Cannot Find a Form?
- Ordering Printed Forms or Wisconsin Administrative Codes or Statutes?
- Looking for a publication?
- Having problems opening a form?
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-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-01454H | IRIS Program Withdrawal Letter – Conflict of Withdrawal | 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 |
| F-01569 | IRIS Consultant Agency (ICA) Transfer Checklist | DMS | None |
| F-01570 | Ice Arena Equipment Maintenance Log | DPH | None |
| F-01571 | Air Quality Measurement Device Maintenance and Calibration Log | DPH | None |
| F-01572 | Ice Arena Log of Pollutant Exceedance | DPH | None |
| F-01573 | Log of Ice Arena Air Quality | DPH | None |
| F-01578 | Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup | DMS | None |
| F-01578A | IRIS SharePoint - Request for User Setup | DMS | None |
| F-01579 | Wisconsin eWIC Cash Register System Survey | DPH | None |
| F-01580 | Noncompliance Roster | DPH | None |
| F-01586 | Medical Stockpile Access Request | DPH | None |
| F-01588 | Application for Available Beds | DMS | None |
| F-01593A | Civil Money Penalty (CMP) Funded Project Report | DQA | None |
| F-01598 | Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents | DMS | None |
| F-01601 | DCTS Summary Line Item Budget | DCTS | None |
| F-01601A | CST Summary Line Item Budget | DCTS | None |
| F-01601B | ISP Line Item Detail Budget | DCTS | None |
| F-01601C | DCTS Summary Line item Budget: Condensed | DCTS | None |
| F-01618 | Client Services Agreement for Medicare Counseling | DPH | None |
| F-01619 | OARS Welcome Letter | DCTS | None |
| F-01620 | Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services | DCTS | None |
| F-01621 | Smoking Cessation Data Collection | DCTS | None |
Pages
Last Revised: March 26, 2019
