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-00388 County Birth to 3 Fiscal Reconciliation Report DMS
F-00390 Incident Report - Community Recovery Services (CRS) DCTS
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care DCTS
F-00401 ForwardHealth Expedited Emergency Supply Request DMS
F-00407 Financial Records Request DMS
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-00417 AODA Prevention Services Recertification Application - DHS 75.04 DQA
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) DQA
F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 DQA
F-00458 TDAP Cocooning Report DPH
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 DQA
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 DQA
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08 DQA
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 DQA
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11 DQA
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12 DQA
F-00471 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Recertification Application - DHS 75.14 DQA
F-00472 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 DQA
F-00473 Community Substance Abuse Services (CSAS) Intervention Service Recertification Application - DHS 75.16 DQA
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36 DQA
F-00476 CARES Automated Systems Access Request DMS
F-00479 Child Outcomes Fidelity Self-Assessment DMS
F-00480 Child Outcomes Summary DMS
F-00482 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Initial Certification Application - Chapter DHS 36 DQA
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 DQA
F-00513 Community Substance Abuse Services (CSAS) Transitional Residential Treatment Service Initial Certification Application - DHS 75.14 DQA
F-00514 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Initial Certification Application - DHS 75.11 DQA
F-00515 Community Substance Abuse Services (CSAS) Day Treatment Service Initial Certification Application - DHS 75.12 DQA
F-00516 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Initial Certification Application - DHS 75.10 DQA
F-00517 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 DQA
F-00518 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Initial Certification Application - DHS 75.08 DQA
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 DQA
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06 DQA
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04 DQA
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 DQA
F-00533 Partnership Programs - Enrollment DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-00537 Community Substance Abuse Services (CSAS) Intervention Services Initial Certification Application - DHS 75.16 DQA
F-00538 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15 DQA
F-00539 Children's Long Term Support Service Coordination Rate Worksheet DMS
F-00539A General Support and Service Coordination Rate Certification Worksheet DMS
F-00543A File Review Checklist DMS
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13 DQA
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05 DQA
F-00546 Community Support Program (CSP) for Persons with Chronic Mental Illness Initial Certification Application - DHS 63 DQA
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 DQA

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Last Revised: March 26, 2019