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-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months DMS
F-01571 Air Quality Measurement Device Maintenance and Calibration Log DPH
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-00726 Typical Vision Developmental Milestones DMS
F-25615 Supervised Release Rules DCTS
F-21076 Informed Consent - Children's Long-Term Support Functional Screen DMS
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application DMS
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08 DQA
F-00261 Personal Care Agency Personnel Record Review DQA
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-62653 Home Health Agency Licensure Survey Entrance Conference Guide DQA
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01389B MHSIP Family Satisfaction Survey DCTS
F-02167 Program Participation System (PPS) PORTAL Report Feedback DCTS
F-00942 Meet Our "Henry" DMS
F-62333 Plan Approval Application and Instructions DQA
F-80983 Civil Rights Complaint DES
F01454G IRIS Program Withdrawal Letter - Cancelled DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) DPH
F-11129B-H Federally Qualified Health Center Cost Report Forms OIG
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter DMS
F-82009Y Confidential Information Release Authorization - Testing Records DCTS
F-00759 Business Associate Agreement - With Contract DES
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-01660 Emergency Medical Staff Patient Tracking Pilot Program Commitment, Wisconsin Healthcare Emergency Preparedness Program (WHEPP) DPH
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
F-10191 Medicaid Annuity Beneficiary Designation DMS
F-02470 IRIS Noncompliance Statement and Corrective Action Plan DMS
F-20465 Declaration of Income DMS
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS
F-01341 Pre-Release from Institution Checklist (CM Checklist) DCTS
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-25207 Order Granting Capias DCTS
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS
F-42001 Tuberculosis Suspect Case Data DPH
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter DMS
F-22565 Authorization for Recoupment Caretaker Supplement DMS
F-01445 Wisconsin eHealth Program Hourly Engagements Request for Services Health Information Technology (HIT) Services Suppliers (Contract Number 435400-P15-eHealth) DMS
F-00615A Change Project Summary and Instructions DPH
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-01411 Education - Medication Summary - Part B DPH
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application DQA
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-80761 Annual Contingent Account Activity Report DES
F-02000 ADRC/Tribal ADRS/Aging System User: Access/Delete/Change DPH
F-02592 Rapid Test and Controls Inventory Log DPH


Last Revised: March 26, 2019