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 Number Titlesort descending Division Other Location
F-02108C Adult Family Home – New Provider Licensure Application DQA
F-02108D Adult Family Home – New Provider Licensure Application Checklist DQA
F-40310 Adult Oral Health Screening DPH
F-21150A Adult Protective Services (APS) Investigation Transfer - Model DPH
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection DPH
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values DPH
F-021343G AFCSP Fiscal Report DPH
F-02217 Affidavit for Supplemental Nutrition Assistance Program – Puerto Rico DMS
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years DMS
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months DMS
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years DMS
F-00367D Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 to 24Months DMS
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months DMS
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years DMS
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years DMS
F-00367B Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months DMS
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years DMS
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years DMS
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months DMS
F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool DMS
F-00639 Agency Data Security Staff User Agreement DMS
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding DMS
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding DMS
F-16050 Agency Position on the State Quality Control (QC) Finding DMS
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-02524 Agent Training Request DCTS
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) DPH
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget DPH
F-00052 Aging and Disability Resource Center (ADRC) Application DPH
F-02034 Aging/ADRC Integration Funding Budget Worksheet DPH
F-02035 Aging/ADRC Integration Funding Request Application DPH
F-00974 Agreement Between State of Wisconsin Department of Health Services WIC and Senior Farmers' Market Nutrition Program (FMNP) and Vendor DPH
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-01646 AIDS/HIV Assistance and Insurance Assistance Program Insurance Enrollment Report DPH
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification DPH
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions DPH
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-62617 Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report DQA
F-02659 Alternate Electronic Visit Verification (EVV) Attestation DMS
F-21343 Alzheimer's Family and Caregiver Support Program (AFCSP) Budget Report DPH
F-21343A Alzheimer's Family and Caregiver Support Program (AFCSP) Financial Eligibility Screen - Worksheets 1 and 2 DPH
F-21343E Alzheimer's Family and Caregiver Support Program (AFCSP) General Information DPH
F-47247 Ambulance Attendant License/Permit Renew DPH
F-47119 Ambulance Report DPH
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments DPH
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA

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Last Revised: March 26, 2019