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 descending Title Division Other Location
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement DMS
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency DQA
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate DMS
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DMS
F-00154 Wisconsin Consultative Examination Inquiry DMS
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application DQA
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum DQA
F-00161 Caregiver Misconduct Reporting Requirements Worksheet DQA
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-00164 Civil Rights Compliance Plan OLC
F-00165 Civil Rights Compliance Letter of Assurance OLC
F-00166 Service Delivery Discrimination Complaint DES
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-00171 Lead Company Application DPH
F-00176 Civil Money Penalty Funds Project Proposal DQA
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-00191 Certified Outpatient Clinic: Request for a Branch Office DQA
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids DMS
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application DCTS
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-00232 Notice of Adverse Benefit Determination (Notice of Action) DMS
F-00233 Renewal Summary Letter DMS
F-00236 Request for a State Fair Hearing - MCO DMS
F-00236A Request for a State Fair Hearing - ADRC DPH
F-00236B Request for a State Fair Hearing - IRIS DMS
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents DMS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results DCTS
F-00261 Personal Care Agency Personnel Record Review DQA
F-00262 Personal Care Agency Application Materials Checklist DQA
F-00262A Personal Care Agency Application Regulatory Guidance Checklist DQA
F-00263 Personal Care Agency Record Review DQA
F-00264 Personal Care Agency Surveyor Guide DQA
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA


Last Revised: March 26, 2019