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 ascending Title Division Other Location
F-01621 Smoking Cessation Data Collection DCTS
F-01620 Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services DCTS
F-01619 OARS Welcome Letter DCTS
F-01618 Client Services Agreement for Medicare Counseling DPH
F-01601C DCTS Summary Line item Budget: Condensed DCTS
F-01601B ISP Line Item Detail Budget DCTS
F-01601A CST Summary Line Item Budget DCTS
F-01601 DCTS Summary Line Item Budget DCTS
F-01598 Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents DMS
F-01593A Civil Money Penalty (CMP) Funded Project Report DQA
F-01588 Application for Available Beds DMS
F-01586 Medical Stockpile Access Request DPH
F-01580 Noncompliance Roster DPH
F-01579 Wisconsin eWIC Cash Register System Survey DPH
F-01578A IRIS SharePoint - Request for User Setup DMS
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup DMS
F-01573 Log of Ice Arena Air Quality DPH
F-01572 Ice Arena Log of Pollutant Exceedance DPH
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-01570 Ice Arena Equipment Maintenance Log DPH
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care DMS
F-01566 IRIS Self-Directed Personal Care (SDPC) – My Cares DMS
F-01565 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Group Practice Patient Volume DMS
F-01564 Wisconsin Medicaid Electronic Health Record (EHR) Incentive Program - Required CEHRT Documentation DMS
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter DMS
F-01558 Risk Agreement – IRIS Program DMS
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-01556D IRIS Program Letter – Disenrollment DMS
F-01556C IRIS Program Cost Share Repayment Plan Letter DMS
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter DMS
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter DMS
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter DMS
F-01556 Medicaid Cost Share Letter - Initial DMS
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility DMS
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility DMS
F-01549 IRIS Certification Designation of Confidential and Proprietary Information DMS
F-01546 IRIS Consultant Agency (ICA) Biography DMS
F-01545 IRIS Fiscal Employer Agent (FEA) Biography DMS
F-01542 Notification of Required Drug Testing DMS
F-01486 IRIS Consultant Biography DMS
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS
F-01468A IRIS Program Start Date Letter – Transferring Participant DMS
F-01468 IRIS Program Start Date Letter – New Participant DMS
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-01454F IRIS Program Withdrawal Letter – Death DMS
F-01454E IRIS Program Withdrawal Letter – Voluntary DMS
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS

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Last Revised: March 26, 2019