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-13393 Trading Partner 835 Designation DMS
F-13470 Claim Form Attachment Cover Page DMS
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) DMS
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-16011 Quality Assurance (QA) Sample Checklist DMS
F-16014 Notice of Program Violation DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-16019A FoodShare Wisconsin Registration DMS
F-16019B FoodShare Wisconsin Registration Packet DMS
F-16021 Student Financial Aid Report DMS
F-16022 Social Security Number Referral DMS
F-16023 Striker Evaluation DMS
F-16024 FoodShare Notice of Disqualification DMS
F-16025 Disqualification Consent Agreement DMS
F-16026 Prosecution Diversion Agreement DMS
F-16028 Notice of FoodShare Overissuance DMS
F-16029 FoodShare Wisconsin Repayment Agreement DMS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-16031 Student Aid and Expense Worksheet DMS
F-16033 FoodShare Worksheet DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-16050 Agency Position on the State Quality Control (QC) Finding DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-16073 FoodShare Wisconsin Nonfinancial Worksheet DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-16104 Local Agency Customer Feedback DMS
F-19002 Request to Reduce QUEST Card Balance DMS
F-20009 Complaint Report DCTS
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation DPH
F-20389 DCTS Program Performance Report DCTS
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection DPH
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS
F-20465 Declaration of Income DMS
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request DPH
F-20572 Request for State Public Funding for Non-Residents DCTS
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS
F-20812 SSI-E Natural Residential Setting Application Checklist DMS
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals DCTS


Last Revised: March 26, 2019