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-01229 WISEWOMAN Provider Assurances and Training Checklist
F-01233 Children's Long-Term Support (CLTS) Waiver program CY 2014 Capacity Building Funding Application
F-01234 Explanation of Medical Benefits
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs
F-01240 IRIS Critical Incident Reconciliation
F-01246 Background Information Disclosure Addendum—IRIS
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment
F-01256 FoodShare Employment and Training (FSET) - Discuss FSET Participation
F-01257 FoodShare Employment and Training (FSET) - Workshop Appointment
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement
F-01261 Fraud Statement - IRIS Program
F-01264 Service Fund Application for Reimbursement
F-01267 Aging and Disability Resource Center (ADRC) Complaint Report
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility
F-01270 Comprehensive Community Services Non-Traditional Approval
F-01275 IRIS Provider Board Member Disclosure
F-01275A IRIS Provider Executive Staff Disclosure
F-01278 Program Participation System (PPS) Employment Questions
F-01279 Program Participation System (PPS) Employment Interview
F-01282 Monthly Enrollment Discrepancy Report Template - Model
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting
F-01286 Template for Transition - Final Plan
F-01287 Template for Transition - Initial Plan - Model
F-01293 Participant Fiscal Employer Agent (FEA) Selection
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-01293D Participant Fiscal Employer Agent (FEA) – Transfer Checklist
F-01302 Weekly Driver's Vehicle Inspection Report
F-01309 IRIS Program Orientation and Enrollment Checklist
F-01310 IRIS Program Conflict of Interest Disclosure – Provider
F-01310A IRIS Program Conflict of Interest Disclosure - Participant
F-01312 IRIS Provider Application
F-01313 Register to Reschedule Lead (Pb) Certification Exam
F-01314 IRIS Program Employment Checklist
F-01319 IRIS Involuntary Disenrollment Request
F-01319B IRIS Denial of Enrollment Request
F-01319C IRIS Program – Denial of Enrollment Letter
F-01319D IRIS Self-Directed Personal Care (SDPC) Involuntary Disenrollment Request
F-01320 Lead Test Kit Documentation
F-01321 Lyme Disease Case Report - Wisconsin
F-01331 Arbovirus Infection Follow-up
F-01332 Predispositional Investigation Report (PDI)
F-01336 Wisconsin Assessment of the Impaired Driver (WAID) and Other Substance Users
F-01337 Worksheet for Determination of Parental Payment Limit for CLTS
F-01338 Children's Long-Term Support Parental Fee Declaration Form - Model


Last Revised: March 26, 2019