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.
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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 Location |
|---|---|---|---|
| F-20448 | Request for Medicaid Administrative Funds – Staff Position | DMS | None |
| F-62457 | Request for Permission to Start Construction for Footings and Foundations | DQA | None |
| F-00330 | Request for Replacement FoodShare Benefits | DMS | None |
| F-20572 | Request for State Public Funding for Non-Residents | DCTS | None |
| F-62608 | Request for Use of Medical Restraints | DMS | None |
| F-00926A | Request for Use of Medical Restraints – CLTS | DMS | None |
| F-62607 | Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan | DMS | None |
| F-00926 | Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan - CLTS | DMS | None |
| F-00569 | Request for Waiver of Administrative Rule for Licensure | DPH | None |
| F-00054 | Request for Waiver of Education / Experience Requirements (ADRC) | DPH | None |
| F-01149 | Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements | DMS | None |
| F-00054A | Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO | DPH | None |
| F-00054B | Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC | DPH | None |
| F-22539 | Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate | DMS | None |
| F-00054D | Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff | DPH | None |
| F-02068 | Request to Establish a Children's COP Risk Reserve | DMS | None |
| F-19002 | Request to Reduce QUEST Card Balance | DMS | None |
| F-00971 | Request to Remove Yellow Fever Vaccine Vaccination Center | DPH | None |
| F-05029 | Request To Withdraw Voluntary Paternity Acknowledgement | DPH | Other |
| F02637 | Requesting FSIA Access During COVID-19 Health Emergency | DMS | None |
| F-02638 | Requesting PPS Access During COVID-19 Health Emergency | DMS | None |
| F-01885 | Requesting State Trauma Registry Access | DPH | None |
| F-00923 | Reschedule Lead (PB) Certification Exam | DPH | None |
| F-69260 | Resident Census and Conditions of Residents CMS-672 | DQA | Other |
| F-62373 | Resident Evacuation Assessment | DQA | None |
| F-02282A | Resident Relocation Plan | DMS | None |
| F-02282 | Resident Relocation Roster | DMS | None |
| F-02634C | Residential Care Apartment Complex (RCAC) Initial Survey Checklist | DQA | None |
| F-40108 | Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program | DPH | None |
| F-01999A | Retired Senior Volunteer Program: State Match Funding Application | DPH | None |
| F-21189 | Rights of Detention | DCTS | None |
| F-62601 | Rights of Home Health Agency Patients | DQA | None |
| F-01558 | Risk Agreement – IRIS Program | DMS | None |
| F-11023 | Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses | DMS | None |
| F-11025 | Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs | DMS | None |
| F-11026 | Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs | DMS | None |
| F-11081 | Rural Health Clinic Provider Staff Encounters | DMS | None |
| F-11027 | Rural Health Clinic Quarterly Cost Report | DMS | None |
| F-11022 | Rural Health Clinic Statistical Data | DMS | None |
| F-45029 | School Food Safety Program Inspection Report | DPH | Other |
| F-04002 | School Report to Local Health Department | DPH | None |
| F-44212 | School Report to the District Attorney | DPH | None |
| F-00107 | Self-Employment Income Report | DMS | None |
| F-00219 | Self-Employment Income Report: Farm Business | DMS | None |
| F-16036 | Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) | DMS | None |
| F-01985 | Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) | DMS | None |
| F-16035 | Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) | DMS | None |
| F-60309 | Self-Supervision Evaluation and Waiver Request | DQA | None |
| F-01999B | Senior Companion Program: State Match Funding Application | DPH | None |
| F-10076 | SeniorCare Application | DMS | Other |
Pages
Last Revised: March 26, 2019
