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 Numbersort ascending Title Division Other Location
F-00470 Community Substance Abuse Services (CSAS) Day Treatment Service Recertification Application - DHS 75.12 DQA
F-00469 Community Substance Abuse Services (CSAS) Medically Monitored Treatment Service Recertification Application - DHS 75.11 DQA
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-00467 Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Recertification Application - DHS 75.09 DQA
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08 DQA
F-00465 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Recertification Application - DHS 75.07 DQA
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 DQA
F-00458 TDAP Cocooning Report DPH
F-00439 Community Substance Abuse Services (CSAS) Emergency Outpatient Service Recertification Application - DHS 75.05 DQA
F-00438 Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) DQA
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS
F-00417 AODA Prevention Services Recertification Application - DHS 75.04 DQA
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-00407 Financial Records Request DMS
F-00401 Prior Authorization/Preferred Drug List (PA/PDL) for Expedited Emergency Supply Request DMS
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care DCTS
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS
F-00390 Incident Report - Community Recovery Services (CRS) DCTS
F-00388 County Birth to 3 Fiscal Reconciliation Report DMS
F-00385 Nurse Aide Training - Student Waiver Request DQA
F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist DQA
F-00380 Outpatient Mental Health Clinic Certification Withdrawal DQA
F-00376 Acknowledgement for Yellow Fever Vaccination Center Certification DPH
F-00375 Yellow Fever Uniform Stamp Application DPH
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-00367K Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 14 - 18 Years DMS
F-00367J Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 - 14 Years DMS
F-00367i Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 9 - 12 Years DMS
F-00367H Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 9 Years DMS
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years DMS
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years DMS
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months DMS
F-00367D Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 to 24Months DMS
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months DMS
F-00367B Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months DMS
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months DMS
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs DMS
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services DMS
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording OS
F-00336 Tickborne Rickettsial Disease Case Report DPH
F-00335 Voluntary Agreement for Crisis Stabilization Services DCTS
F-00334 Money Follows the Person (MFP) - Participant Reporting DMS
F-00332 Medicaid Purchase Plan Premium Information / Payment DMS
F-00330 Request for Replacement FoodShare Benefits DMS
F-00321 OBVI Initial Interview Assessment DPH
F-00316 Child Enrollment Status Regarding Birth to 3 Program DMS
F-00315D Written Prior Notice - Additional Assessment Recommended DMS

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Last Revised: March 26, 2019