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 ascending
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-01649 Coverdell Stroke Champion Partner Agreement DPH
F-00926A Request for Use of Medical Restraints – CLTS DMS
F-47125 Emergency Medical Technician - Intermediate Training Permit Application DPH
F-02463 Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement DPH
F-11048 Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS
F-00989L Summary of Services (IFSP) DMS
F-44322 Vendor / Participant Complaint - Wisconsin Women, Infant, and Children (WIC) Program DPH
F-02383 HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary DMS
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility DMS
F-02067 Women, Infants, and Children (WIC) Staff Training Record DPH
F-00603 PPS (Program Participation System) Core Module DES
F-10162 Verification of Veterans Benefits DMS
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy DPH
F-05260 Letter of Non-Marriage Application DPH
F-01220 WISEWOMAN Healthy Lifestyle Assessment DPH
F-00315C Prior Notice and Consent for Evaluation and Assessment DMS
F-02074 Medicare Other Coverage Discrepancy Report DMS
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS
F-80190 Travel Reimbursement Request Non-State Employee DES
F-00161A Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source DQA
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses DMS
F-01997 Children's Community Options (CCOP) Reconciliation Packet DMS
F-00004 Health and Employment Counseling Application DMS
F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo DMS
F-62504 Behavioral Health Certification Section: Initial Certification Application DQA
F-02601 Wisconsin 1-2 Bed Adult Family Home (AFH) Application DMS
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request DMS
F-01708 Case Management Comprehensive Assessment DPH
F-01063 HealthCheck Family History DMS
F-62023 Report of Hours Worked - Registered Nurse / Day DQA
F-02106C Adult Day Care Center – New Provider Certification Application DQA
F-01588 Application for Available Beds DMS
F-02400B Client Transfer: Labels DQA
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography DPH
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-01549 IRIS Certification Designation of Confidential and Proprietary Information DMS
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 DQA
F-44012 Lead Abatement Notification DPH
F-01999B Senior Companion Program: State Match Funding Application DPH
F-10137 Medicaid Change Report DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-00388 County Birth to 3 Fiscal Reconciliation Report DMS
F-40065 The Emergency Food Assistance Program (TEFAP) Storage Facility Review Monitoring Report DPH
F-02193 Verifying Tax-Exempt Income for Live-In Care Providers DMS
F-82006 Employment Application and Resume DES
F-00263 Personal Care Agency Record Review DQA
F-22540A Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs Worksheet OS


Last Revised: March 26, 2019