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 ascending
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request DQA
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-00565 County Performance Plan (CPP) DMS
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report DPH
F-10141 Wisconsin Funeral and Cemetery Aids Program Application DMS
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program DMS
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care DCTS
F-40092 Physical Activity Zone DPH
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH
F-00039 Asbestos Course Accreditation - Initial DPH
F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook DCTS
F-22571 Caretaker Supplement Application DMS
F-02191 CLTS County Waitlist Transition Plan DMS
F-01264 Service Fund Application for Reimbursement DPH
F-80112 Vendor Validation DES
F-02739 Family Care Partnership Letter about Your Right to Make a Fast Complaint DMS
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-02047 IRIS Financial Reporting Template DMS
F-62457 Request for Permission to Start Construction for Footings and Foundations DQA
F-02610 Owner-Occupied Properties - Lead-Safe Homes Program Application DPH
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH
F-02013 TEFAP Confidentiality and Nondisclosure Agreement Staff and/or Volunteer working at TEFAP Distribution Outlets DPH
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-60309 Self-Supervision Evaluation and Waiver Request DQA
F-11130 Federally Qualified Health Center Interim Report DMS
F-01627 OARS Provider Case Manager Checklist DCTS
F-00759 Business Associate Agreement: With Contract DES
F-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-02495 Vaccine for Adults (VFA) Provider Agreement DPH
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change DMS
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 DQA
F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation DPH
F-02432 IRIS Program HIPAA Breach and Unauthorized Disclosure Reporting DMS
F-01454C IRIS Program Withdrawal Letter – No Contact DMS
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement DPH
F-25393A Petition for Supervised Release DCTS
F-01411 Education - Medication Summary - Part B DPH
F-02163 Tuberculosis Ordering and Billing Interface (TOBI) User Security and Confidentiality Agreement DPH
F-02642 Report a Change in Circumstance to Income Maintenance Agencies DMS
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06 DQA
F-43026 Wisconsin Donor Registry User Access Request DPH
F-20920 Formula to Determine Amount of Income Available to Pay for Room & Board in Substitute Care DMS
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years DMS

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Last Revised: March 26, 2019