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 Numbersort descending Title Division Other Location
F-01428 Birth to 3 Program Invitation to Individualized Family Service Plan Meeting (IFSP) DMS
F-01430 Prior Authorization Drug Attachment for Xyrem DMS
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) DMS
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) DMS
F-01442 IRIS Disenrollment Letter - Death DMS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility DMS
F-01442C IRIS Program Disenrollment Letter – No Contact DMS
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen DMS
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting DMS
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page DMS
F-01442G IRIS Program Disenrollment Letter – Non-Spending DMS
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-01442J IRIS Program Disenrollment Letter - Mismanagement DMS
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) DMS
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) DMS
F-01454 IRIS Program Withdrawal Letter – No Progress DMS
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS
F-01454C IRIS Program Withdrawal Letter – No Contact DMS
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS
F-01454E IRIS Program Withdrawal Letter – Voluntary DMS
F-01454F IRIS Program Withdrawal Letter - Death DMS
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH
F-01486 IRIS Consultant Biography DMS
F-01542 Notification of Required Drug Testing DMS
F-01545 IRIS Fiscal Employer Agent (FEA) Biography DMS
F-01546 IRIS Consultant Agency (ICA) Biography DMS
F-01549 IRIS Certification Designation of Confidential and Proprietary Information DMS
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility DMS
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility DMS
F-01556 Medicaid Cost Share Letter - Initial DMS
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter DMS
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter DMS
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter DMS
F-01556C IRIS Program Cost Share Repayment Plan Letter DMS
F-01556D IRIS Program Letter – Disenrollment DMS
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-01558 Risk Agreement – IRIS Program DMS
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter DMS
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation DMS
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume DMS
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares DMS
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS

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Last Revised: March 26, 2019