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-01153 Breast Pump Order DMS
F-01944 Assessment, Feedback, Incentives, eXchange (AFIX) Adult Immunization Questionnaire DPH
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-02536 Nursing Home: Waiver or Variance Request DQA
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS
F-00195 IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program DMS
F-62028 Report of Hours Worked - Nurse Aide / Night DQA
F-20941 Informed Consent for Participation in Wisconsin's Money Follows the Person (MFP) Demonstration DMS
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist DMS
F-01421 WISEWOMAN Monthly Reporting for Direct Services DPH
F-10161 Statement of Citizenship and/or Identity DMS
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement DPH
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-00367D Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 to 24Months DMS
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-42017 Wisconsin Initial Refugee Health Assessment DPH
F-44323 WIC Stock Price Survey – Pharmacy Only DPH
F-01389 ROSI Adult Satisfaction Survey DCTS
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00367E Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 24 to 36 Months DMS
F-00676 Youth Transition Pretest DPH
F-42023 Vaccine Celsius Temperature Log DPH
F-44444 WIC Vendor Supply Order DPH
F-01389A MHSIP Youth Satisfaction Survey DCTS
F-11042 Prior Authorization Amendment Request DMS
F-26100 Client Rights Limitation or Denial Documentation DCTS
F-02138 Home and Community-Based Services (HCBS) Compliance Review Request DQA
F-80976 Employment and Education History Summary DES
F-01293 Participant Fiscal Employer Agent (FEA) Selection DMS
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard DMS
F-01442i IRIS Program Disenrollment Letter - Cancelled DMS
F-62657 Home Health Agency Contract Review Worksheet DQA
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request DMS
F-62370 Significant Change in Health Screening Instrument Model Form DQA
F-02529 Accreditation Mentoring Program - Mentee Application DPH
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-44614B AIDS/HIV Drug Insurance Premium Subsidy Program and Drug Assistance Program Application/Recertification Part B - Physician Portion DPH
F-00157 Assisted Living Administrator Training Course - Trainer Approval Application DQA
F-01068L General Pediatric Clinic - Teenager Visit DMS
F-02467 Children's Long-Term Support: Care Level Classification DMS
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-00523 Community Substance Abuse Service (CSAS) General Requirements Initial Certification Application - DHS 75.03 DQA
F-00046 Family Care Program - Enrollment DPH
F-00596a PPS Mental Health Deskcard DCTS
F-01556 Medicaid Cost Share Letter - Initial DMS
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-20935 Status Report to Court for Plan Compliance DCTS
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG


Last Revised: March 26, 2019