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-00315 Written Prior Notice DMS
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-00311 Nursing Home MDS 3.0 Section Q Referral DQA
F-00309 Medicaid Provider Report DQA
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments DPH
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service DQA
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application DCTS
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA
F-00264 Personal Care Agency Surveyor Guide DQA
F-00263 Personal Care Agency Record Review DQA
F-00262A Personal Care Agency Application Regulatory Guidance Checklist DQA
F-00262 Personal Care Agency Application Materials Checklist DQA
F-00261 Personal Care Agency Personnel Record Review DQA
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents DMS
F-00236B Request for a State Fair Hearing - IRIS DMS
F-00236A Request for a State Fair Hearing - ADRC DPH
F-00236 Request for a State Fair Hearing - MCO DMS
F-00233 Renewal Summary Letter DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-00219 Self-Employment Income Report: Farm Business DMS
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application DCTS
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids DMS
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-00191 Certified Outpatient Clinic: Request for a Branch Office DQA
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-00176 Civil Money Penalty Funds Project Proposal DQA
F-00171 Lead Company Application DPH
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-00166 Service Delivery Discrimination Complaint DES
F-00165 Civil Rights Compliance Letter of Assurance OLC
F-00164 Civil Rights Compliance Plan OLC
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-00161 Caregiver Misconduct Reporting Requirements Worksheet DQA

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Last Revised: March 26, 2019