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 Other Location
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-01446 Wisconsin eHealth Program Project-Based Work Request for Services - Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth)
F-01454 IRIS Program Withdrawal Letter – No Progress
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-01454B IRIS Program Withdrawal Letter – Health and Safety
F-01454C IRIS Program Withdrawal Letter – No Contact
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting
F-01454E IRIS Program Withdrawal Letter – Voluntary
F-01454F IRIS Program Withdrawal Letter - Death
F-01468 IRIS Program Start Date Letter – New Participant
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request
F-01481 Marriage Record Amendment Request Officiant Affidavit
F-01486 IRIS Consultant Biography
F-01542 Notification of Required Drug Testing
F-01545 IRIS Fiscal Employer Agent (FEA) Biography
F-01546 IRIS Consultant Agency (ICA) Biography
F-01549 IRIS Certification Designation of Confidential and Proprietary Information
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility
F-01556 Medicaid Cost Share Letter - Initial
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-01556D IRIS Program Letter – Disenrollment
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-01558 Risk Agreement – IRIS Program
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist
F-01570 Ice Arena Equipment Maintenance Log
F-01571 Air Quality Measurement Device Maintenance and Calibration Log
F-01572 Ice Arena Log of Pollutant Exceedance
F-01573 Log of Ice Arena Air Quality
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup
F-01578A IRIS SharePoint - Request for User Setup
F-01579 Wisconsin eWIC Cash Register System Survey
F-01580 Noncompliance Roster
F-01586 Medical Stockpile Access Request
F-01588 Application for Available Beds
F-01593A Civil Money Penality (CMP) Funded Project Report
F-01598 Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents
F-01601 DCTS Summary Line Item Budget
F-01601A CST Summary Line Item Budget
F-01601B ISP Line Item Detail Budget

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Last Revised: March 26, 2019