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-21336 Consent for Exchange of Information with Local Educational Agency DMS
F-21334 Encounter New User Request DMS
F-21276A DCTS Coordinated Services Teams (CST) Grant / Contract Application Summary DCTS
F-21276 DCTS Annual Grant/Contract Application DCTS
F-21232 Children's Long Term Support (CLTS) Waivers Child Information Eligibility Worksheet DMS
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard DMS
F-21225A Program Participation System (PPS): B-3 Module DMS
F-21225 Program Participation System (PPS): B-3 Module DMS
F-21189 Rights of Detention DCTS
F-21150A Adult Protective Services (APS) Investigation Transfer - Model DPH
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers DPH
F-21088 Substance Abuse Prevention Services Information System (SAP-SIS) Agency / User Web Access Request DCTS
F-21076 Informed Consent - Children's Long-Term Support Functional Screen DMS
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting DMS
F-21059 Variance Request for Institution Respite DMS
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-20985 Participant Rights and Responsibilities Notification DMS
F-20942A Total Expenses All Sources by Target Group and Standard Program Cluster Worksheet OPIB
F-20941 Informed Consent for Participation in Wisconsin's Money Follows the Person (MFP) Demonstration DMS
F-20935 Status Report to Court for Plan Compliance DCTS
F-20934A Plan Recommendation DCTS
F-20934 Court Ordered Assessment and Plan Report DCTS
F-20933 Court Order for Assessment DCTS
F-20920 Formula to Determine Amount of Income Available to Pay for Room & Board in Substitute Care DMS
F-20919D Declaration Regarding Transfer of Resources Long-Term Care Medicaid Waiver Program and/or Community Options Program DMS
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals DCTS
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-20812 SSI-E Natural Residential Setting Application Checklist DMS
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS
F-20572 Request for State Public Funding for Non-Residents DCTS
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request DPH
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection DPH
F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool DMS
F-20389 DCTS Program Performance Report DCTS
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation DPH
F-20009 Complaint Report DCTS
F-19002 Request to Reduce QUEST Card Balance DMS
F-16104 Local Agency Customer Feedback DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-16073 FoodShare Wisconsin Nonfinancial Worksheet DMS
F-16066 FoodShare Wisconsin Income Change Report DMS

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Last Revised: March 26, 2019