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-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Intitial Certification Application - DHS 75.06
F-00521 Community Substance Abuse Services (CSAS) Prevention Service Initial Certification Application - DHS 75.04
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03
F-00533 PACE / Partnership Programs - Enrollment
F-00534 PACE / Partnership Member Requested Disenrollment
F-00537 Community Substance Abuse Services (CSAS) Intervention Services Initial Certification Application - DHS 75.16
F-00538 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Initial Certification Application - DHS 75.15
F-00539 Children's Long Term Support Service Coordination Rate Worksheet
F-00539A General Support and Service Coordination Rate Certification Worksheet
F-00543A File Review Checklist
F-00544 Community Substance Abuse Services (CSAS) Outpatient Treatment Service Initial Certification Application - DHS 75.13
F-00545 Emergency Outpatient Service Initial Certification Application - DHS 75.05
F-00546 Community Support Program (CSP) for Persons with Chronic Mental Illness Initial Certification Application - DHS 63
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34
F-00553 Professional & Occupational License Application & Affidavit
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-00565 County Performance Plan (CPP)
F-00565A County Performance Plan (CPP) Outcomes
F-00567 Emergency Medical Services Complaint
F-00568 EMS Board Sub-Committee Appointment Application
F-00569 Request for Waiver of Administrative Rule for Licensure
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS)
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application
F-00576A Tribal Aging and Disability Resource Specialist (TADRC) Annual Budget
F-00577 Report Fraud
F-00580 Nursing Home Authorization for Access to Automated MDS 3.0 Section Q Referral Management System
F-00588 PPS Alcohol and Other Drug Abuse Module
F-00588a PPS AODA Deskcard
F-00596 PPS Mental Health Module
F-00596a PPS Mental Health Deskcard
F-00603 PPS (Program Participation System) Core Module
F-00603a PPS Core Deskcard
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application
F-00615 Change Project Report and Instructions
F-00615A Change Project Summary and Instructions
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable
F-00628 Consortium Response to the State IM Second Party Review Finding
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information
F-00633 Notice and Consent for Screening
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program
F-00634B Records Access Log, Birth to 3 Program
F-00639 Agency Data Security Staff User Agreement
F-00642 Community Aids Reporting System (CARS) Expenditure Report
F-00646 Emergency Medical Service Training Center - Training Permit Eligibility Certification
F-00653 Importing Procedure Records in NHSN (SSI DENOMINATOR)


Last Revised: July 28, 2017