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-00367D Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 to 24Months
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application (PDF, 53 KB)
F-00375 Yellow Fever Uniform Stamp Application
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification
F-00380 Outpatient Mental Health Clinic Certification Withdrawal
F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist
F-00385 Nurse Aide Training - Student Waiver Request
F-00386 Nurse Aide Training Program – Application for ADA Accommodation During Nurse Aide Testing
F-00388 County Birth to 3 Fiscal Reconciliation Report
F-00390 Incident Report - Community Recovery Services (CRS)
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care
F-00401 Expedited Emergency Supply Request
F-00407 Financial Records Request
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information
F-00417 AODA Prevention Services Recertification Application - DHS 75.04
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11)
F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05
F-00458 TDAP Cocooning Report
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14
F-00472 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36
F-00476 CARES Automated Systems Access Request
F-00478 Quality of Life Survey - Money Follows the Person (MFP)
F-00479 Child Outcomes Fidelity Self-Assessment
F-00480 Child Outcomes Summary
F-00482 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Initial Certification Application - Chapter DHS 36
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75
F-00513 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Initial Certification Application - DHS 75.14
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11
F-00515 Community Substance Abuse Services (CSAS) Day Treatment Service Initial Certification Application - DHS 75.12
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09

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Last Revised: May 22, 2018