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-00989P Individualized Family Service Plan Team Signature (IFSP) DMS
F-44444 WIC Vendor Supply Order DPH
F-02385 Vaccine Accountability -Vaccine Preventable Disease: Tetanus DPH
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06 DQA
F-00759 Business Associate Agreement - With Contract DES
F-01012 Reimbursement Request for a PASRR Level I Screen DMS
F-00466 Community Substance Abuse Services (CSAS) Ambulatory Detoxification Service Recertification Application - DHS 75.08 DQA
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F-42016 Authorization for Release of Confidential HIV Test Results DPH
F-02241 Hepatitis A Worksheet Confirmed and Suspected Cases DPH
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS
F-26003A Notice of Privacy Practices - Treatment Facilities - NON-HCC DCTS
F-02080 Dementia Crisis Innovation Grants: Round Two DPH
F-80477B Canteen Operations Balance Sheet - GAAP Basis DES
F-00004A Health and Employment Counseling - I Think I Need More Time DMS
F-01949A Tribal ADRS Annual Update DPH
F-62372 Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation DQA
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-62601 Rights of Home Health Agency Patients DQA
F-01735 CLIA Laboratory Test Methodology Report DQA
F-02108C Adult Family Home – New Provider Licensure Application DQA
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 DMS
F-00380 Outpatient Mental Health Clinic Certification Withdrawal DQA
F-00639 Agency Data Security Staff User Agreement DMS
F-10193 Undue Hardship Waiver Request DMS
F-01601 DCTS Summary Line Item Budget DCTS
F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography DPH
F-01947 IRIS Participant Education Manual: Acknowledgement DMS
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DMS
F-22491AL Consumer Survey – OBVI (Large Print) DPH
F-44018 Request for Repairs DPH
F-02349 Children's Long-Term Support (CLTS) Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for County Waiver Agencies DMS
F-00642 Community Aids Reporting System (CARS) Expenditure Report DES
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement DPH
F-02108 Adult Family Home – Applicant Compliance Statement DQA
F-83263 Rehabilitation Review Application and Instructions OS
F-22678 Community Relocation Initiative Initial Care Plan Information and Funding Estimate DMS
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer DCTS
F-20582 Medicaid – Katie Beckett Program Application and Recertification DMS
F-00926A Request for Use of Medical Restraints – CLTS DMS
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-11285 HealthCheck Screener Affirmation OIG
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation DCTS
F-11027 Rural Health Clinic Quarterly Cost Report DMS
F-80025 Forms / Publications Order OS
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline DMS
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs DMS
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application DPH


Last Revised: March 26, 2019