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-00219 Self-Employment Income Report: Farm Business DMS
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-00203 Community Recovery Services (CRS) - County / Tribal Agency Application DCTS
F-00202 Individual Service Plan - Community Recovery Services (CRS) DCTS
F-00201 Occupant Protection Plan Checklist for Lead-Based Paint Activities DPH
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids DMS
F-00193 Pediatric Referral / Communication Wisconsin WIC Program DPH
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-00191A Certified Outpatient Clinic: Request for a School Branch Office DQA
F-00191 Certified Outpatient Clinic: Request for a Branch Office DQA
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-00176 Civil Money Penalty Funds Project Proposal DQA
F-00171 Lead Company Application DPH
F-00169 Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification DMS
F-00166 Service Delivery Discrimination Complaint DES
F-00165 Civil Rights Compliance Letter of Assurance OLC
F-00164 Civil Rights Compliance Plan OLC
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-00161 Caregiver Misconduct Reporting Requirements Worksheet DQA
F-00158 Assisted Living Administrator Training Course - Application for Training Curriculum DQA
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application DQA
F-00154 Wisconsin Consultative Examination Inquiry DMS
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DMS
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate DMS
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-00140 Attestation and Acknowledgement for Provisional Approval as a Personal Care Agency DQA
F-00136 FoodShare Employment and Training (FSET) Program Participation Agreement DMS
F-00124 Wisconsin Termination of Domestic Partnership Certificate Application DPH
F-00123 Wisconsin Declaration of Domestic Partnership Application DPH
F-00119 Personal Care Agency Application for Approval DQA
F-00116 Wisconsin Blood Lead Registry Organization Security and Confidentiality Agreement DPH
F-00115 Wisconsin Uniform Placement Criteria (WI-UPC) Adult Placement Scoring Instrument DCTS
F-00114 EMS Service Director License Proxy for Individuals DPH
F-00107 Self-Employment Income Report DMS
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement DPH
F-00101 Authorization to Request Birth Records DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-00098 Summary of Information Letter DMS
F-00086 Authorization for Final Disposition DPH
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine DMS
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-00060 Declaration to Physicians (Living Will) DPH
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
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
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

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Last Revised: March 26, 2019