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-62536 Home Health Agency ACCS Initial Application / Pre-licensure Desk Review Checklist DQA
F-62281 Care Level Change Notice DQA
F-02107A Family Adult Day Care Center – Established Provider Certification Application DQA
F-01618 Client Services Agreement for Medicare Counseling DPH
F-21059 Variance Request for Institution Respite DMS
F-22468 Application for Services Office for the Blind and Visually Impaired DPH
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-16038 Administrative Disqualification Hearing Notice DMS
F-00004B Health and Employment Counseling - I Have Reached Employment DPH
F-00355 Healthiest Wisconsin 2020 Implementation Plan Endorsement DPH
F-04003 Vendor Monitoring Worksheet - Wisconsin WIC Program DPH
F-00475 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders: Recertification Application – DHS 36 DQA
F-47463D Intermediate Operational Plan Components DPH
F-13146 HIPAA Privacy Revocation of Authorization DMS
F-00989D Summary of Development Child’s Use of Knowledge and Skills (IFSP) DMS
F-01209 IRIS Certification Acknowledgment DMS
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies DMS
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-01427 Birth to 3 Invitation to Early Intervention (EI) Team Eligibility Determination and Individualized Family Service Plan (IFSP) Meeting DMS
F-01068M Confidential Health Survey DMS
F-02057 ADRC Authorization for the Release of Confidential Information DPH
F-01408 Asthma Control Summary DPH
F-44001A Legal Notice: Required Immunizations for Admission to Wisconsin Child Care Centers DPH
F-00659 Substance Abuse Block Grant Prevention Program / Practice Approval DCTS
F-80130 Financial Information  DES
F-01763 The Emergency Food Assistance Program (TEFAP) - Review Findings for Food Pantries, Soup Kitchens and Shelters DPH
F-01428 Birth to 3 Program Invitation to Individualized Family Service Plan Meeting (IFSP) DMS
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program DPH
F-01104 Specialized Psychiatric Rehabilitation Services (SPRS) Monthly Roster DMS
F-02191 CLTS County Waitlist Transition Plan DMS
F-01218 WISEWOMAN Client Consent DPH
F-02059 New Carrier Insurance Disclosure Onboarding DMS
F-00676 Youth Transition Pretest DPH
F-80142 Collections Delegation Application DES
F-01764 The Emergency Food Assistance Program (TEFAP) - Food Pantry Review DPH
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS
F-10191 Medicaid Annuity Beneficiary Designation DMS
F-42010 Interjurisdictional Tuberculosis Notification DPH
F-00923 Reschedule Lead (PB) Certification Exam (PDF, 90 KB) DPH
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS
F-25904 Admission to Caseload - Revocation DCTS
F-00171 Lead Company Application DPH
F-62548 Assisted Living Facility Waiver, Approval, Variance, or Exception Request DQA
F-21189 Rights of Detention DCTS
F-00261 Personal Care Agency Personnel Record Review DQA
F-01622 OARS Records Checklist DCTS
F-62096A DQA Authority for Obtaining Provider Records Without Written Release DQA
F-01578 Wisconsin’s Self-Directed IT System (WISITS) – Request For User Setup DMS
F-01312 IRIS Provider Application DMS
F-47141 Emergency Medical Technician-Paramedic Training Permit Application DPH


Last Revised: March 26, 2019