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-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-Specified Community Recovery Services Providers DCTS
F-80464 Physical and Capital Inventory Compliance Certification DES
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-62569 Individual Provider Status Approval Application and Supervisor Affidavit DQA
F-40073 Monthly Physical Activity Sheet DPH
F-01788 Certification Regarding Debarment and Suspension DES
F-00040 Asbestos Course Accreditation - Renewal DPH
F-02527 Waiver or Variance Request: Hospital (DHS 124), Home Health Agency (DHS133), and Hospice (DHS 131) DQA
F-45019 Reciprocity Privileges Checklist DPH
F-22553A Free In-Service or Educational Training Request DPH
F-01644 Parents Who Host, Lose The Most Application DCTS
F-00912 Wisconsin Coordinated Services Team (CST) Initiative, Request for Training and Technical Assistance DCTS
F-02460 OBVI Bold Lined Paper DPH
F-00989H Child/Family Outcome (IFSP) DMS
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-20934 Court Ordered Assessment and Plan Report DCTS
F-01442 IRIS Disenrollment Letter - Death DMS
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-02242 Hepatitis A High-Risk Occupations Questionnaire DPH
F-00944 Request for Approval: Comprehensive Community Services (CCS) Regional Service Model DCTS
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA
F-20934A Plan Recommendation DCTS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis DMS
F-02250 Quarterly Program Integrity Report OIG
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral DPH
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet OS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-21189 Rights of Detention DCTS
F-00261 Personal Care Agency Personnel Record Review DQA
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08 DQA
F-16011 Quality Assurance (QA) Sample Checklist DMS
F-62447 Misconduct Incident Report DQA
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) DPH
F-10162 Verification of Veterans Benefits DMS
F-01715 Calculating Expenses for a CLTS Foster Home Using Actual Expenses DMS
F-02109D CBRF – New Provider Licensure Application Checklist DQA
F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) DPH
F-01586 Medical Stockpile Access Request DPH
F-00785 Outpatient Mental Health Clinic Recertification Application - DHS 35 DQA
F-21059 Variance Request for Institution Respite DMS
F-00634B Records Access Log, Birth to 3 Program DMS
F-00533 Partnership Programs - Enrollment DPH
F-60290 Community Based Residential Facility (CBRF) Identification of Hazards Request DQA
F-01210A IRIS Budget Amendment Provider Quote Comparison DMS
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services DCTS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH

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Last Revised: March 26, 2019