Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Numbersort descending Title Division Other Location
F-12029 Managed Care Disenrollment Request DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions DMS
F-13033 Probate Claims Notice DMS
F-13038 Notice of Intent to File a Lien (Paper Only. Follow link to order paper copy.) DMS
F-13066 Claim Refund DMS
F-13072 Noncompound Drug Claim DMS
F-13073 Compound Drug Claim DMS
F-13074 Pharmacy Special Handling Request DMS
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS
F-13146 HIPAA Privacy Revocation of Authorization DMS
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS
F-13148 HIPAA Privacy Access Request DMS
F-13149 HIPAA Privacy Accounting Request DMS
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS
F-13151 HIPAA Privacy Amendment Request DMS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request DMS
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request DMS
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request DMS
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request DMS
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization DMS
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
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-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

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Last Revised: March 23, 2021