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-60795 Community Based Residential Facility (CBRF) Fire Inspection DQA
F-01234 Explanation of Medical Benefits DMS
F-01020 Nursing Home Care Determination Request DMS
F-11260 Degree Addendum OIG
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS
F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) DPH
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-01486 IRIS Consultant Biography DMS
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers DMS
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-44001 Legal Notice: Required Immunizations for Admission to Wisconsin Schools DPH
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS
F-01389B MHSIP Family Satisfaction Survey DCTS
F-00565A County Performance Plan (CPP) Goals DMS
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification DPH
F-80976 Employment and Education History Summary DES
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) DPH
F-02046 IRIS Financial Projections Template DMS
F21276C DCTS Annual Grant/Contract Application: Conde DCTS
F-62657 Home Health Agency Contract Review Worksheet DQA
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-02565 Community Recovery Services (CRS) Staff Background Check Confirmation DCTS
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-01146 Wisconsin Chronic Disease Program Provider Data Sheet DMS
F-62320 Hospice Survey Information DQA
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS
F-01619 OARS Welcome Letter DCTS
F-00987A EMS Service Operational Plan Advanced Skills Addendum (Intermediate) DPH
F-47463D Intermediate Operational Plan Components DPH
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-01275A IRIS Provider Executive Staff Disclosure DMS
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-00657 Nurse Aide Training Program: Military Training Verification DQA
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels DPH
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-01454B IRIS Program Withdrawal Letter – Health and Safety DMS
F-02188 Lyme Disease Case Worksheet DPH
F-42023 Vaccine Celsius Temperature Log DPH
F-01409 Client Information Intake DPH
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-10097 Medicaid Income Allocation Notice DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-26003 Notice of Privacy Practices - Treatment Facilities - HCC DCTS
F-01341 Pre-Release from Institution Checklist (CM Checklist) DCTS
F-80761 Annual Contingent Account Activity Report DES


Last Revised: March 26, 2019