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 Title Division Other Locationsort descending
F-01454 IRIS Program Withdrawal Letter – No Progress DMS
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement DPH
F-00472 Community Substance Abuse Services (CSAS) Narcotic Treatment Service for Opiate Addiction Recertification Application - DHS 75.15 DQA
F-25213 Admission to Caseload - Mental Health DCTS
F-02140 Urgent Services Agreement DPH
F-00330 Request for Replacement FoodShare Benefits DMS
F-01319 IRIS Involuntary Disenrollment Request DMS
F-80476 Asset Transfer DES
F-02700 Wisconsin COVID-19 Patient Information DPH
F-21072 Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting DMS
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES) DMS
F-00165 Civil Rights Compliance Letter of Assurance OLC
F-01200 IRIS Program Cost Share Repayment Agreement DMS
F-62579 Post Survey Questionnaire DQA
F-02614 Fraud Prevention and Investigation Program (FPIP) Fraud Year Contact Information OIG
F-00021 HealthCheck Referral DMS
F-13470 Claim Form Attachment Cover Page DMS
F-00575 Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) DPH
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-62028 Report of Hours Worked - Nurse Aide / Night DQA
F-02528 Accreditation Mentoring Program - Mentor Application DPH
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG
F-01631 ADRC Call Summary Sheet DPH
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources DPH
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP) DMS
F-20934A Plan Recommendation DCTS
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-00567 Emergency Medical Services Complaint DPH
F-44063 Lead (Pb) Principal Instructor Application DPH
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS
F-01430 Prior Authorization Drug Attachment for Xyrem DMS
F-40075 Pedometer Walking Program DPH
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer DMS
F-00401 Prior Authorization/Preferred Drug List (PA/PDL) for Expedited Emergency Supply Request DMS
F-83263 Rehabilitation Review Application and Instructions OS
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors DPH
F-02068 Request to Establish a Children's COP Risk Reserve DMS
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility DCTS
F-20389 DCTS Program Performance Report DCTS
F-01768 The Emergency Food Assistance Program - Soup Kitchen Review DPH
F-62441 Report of Hours Worked - Other Direct Care Nurse Aide / Evening DQA
F-01593A Civil Money Penalty (CMP) Funded Project Report DQA
F-02109D CBRF – New Provider Licensure Application Checklist DQA
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument DCTS
F-01170 Written Correspondence Inquiry DMS
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS
F-47489 EMS Patient Care Worksheet DPH

Pages

Last Revised: March 26, 2019