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-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request DMS
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request DMS
F-12025 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-01003 Wisconsin Medicaid Certification of Public Expenditures DMS
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds) DMS
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
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-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older 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-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election DMS
F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness DMS
F-01477 Wisconsin Medicaid Program Nursing Home Cost Report Website User Request DMS
F-01439 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Consultant Agencies (ICA) DMS
F-01438 Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for IRIS Fiscal Employer Agents (FEA) DMS
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model DMS
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application DMS
F-00986 Wisconsin Newborn Screening Program (NBS) - Condition Nomination DPH
F-01844 Wisconsin Notification of Death – Accounting of Estate Funds DMS
F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC) DPH
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) DPH
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request DMS
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request DMS
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization DMS
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-02314 Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation DPH
F-02314E Wisconsin Tuberculosis (TB) Risk Assessment and Symptom Evaluation for Annual Employee Screening DPH
F-02314A Wisconsin Tuberculosis (TB) Risk Assessment Questionnaire Screen for Wisconsin Public School Employees DPH
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument DCTS
F-10147 Wisconsin Veterans Home at King - Medicaid Review DMS
F-10075 Wisconsin Well Woman Medicaid Application and Renewal DMS
F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral DPH
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-44089 Wisconsin WIC Checks Accepted Here - Stickers DPH
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-01367 Wisconsin WIC Referral / Communication to CYSHCN Regional Center DPH

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Last Revised: March 26, 2019