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-01947 IRIS Participant Education Manual: Acknowledgement DMS
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter DMS
F-00367L Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 18 Years and Up DMS
F-40063 TEFAP / CSFP Commodities Complaint DPH
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-01319C IRIS Program – Denial of Enrollment Letter DMS
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-44011 Application for Registration of Lead-Free or Lead-Safe Property DPH
F-02403 Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment DPH
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bed-Hold Days DMS
F-00368 Wisconsin Lead (Pb) Course Accreditation - Initial or Renewal Application DPH
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs 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-01204B Letter – IRIS Program Notice of Action – Limit DMS
F-20418 Agency Application for Access to Web-Based Personal Care Screening Tool DMS
F-62680 Home Health Agency (HHA): Clinical Record Review (State Only) DQA
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance DMS
F-02634C Residential Care Apartment Complex (RCAC) Initial Survey Checklist DQA
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-01146 Wisconsin Chronic Disease Program Provider Data Sheet DMS
F-62370 Significant Change in Health Screening Instrument Model Form DQA
F-13149 HIPAA Privacy Accounting Request DMS
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter DMS
F-00987A EMS Service Operational Plan Advanced Skills Addendum (Intermediate) DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording OS
F-00657 Nurse Aide Training Program: Military Training Verification DQA
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers DPH
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-00989P Individualized Family Service Plan Team Signature (IFSP) DMS
F-42030 Authorization to Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine DPH
F-02425 Wisconsin Alzheimer’s Family Caregiver Support Program (AFCSP) Home-Delivered Meals Donation Authorization DPH
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting DMS
F-02284 Record of School Employee Examination DPH
F-10097 Medicaid Income Allocation Notice DMS
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application DMS
F-40019 Affirmation of Identity, Residency, and/or Income DPH
F-01341 Pre-Release from Institution Checklist (CM Checklist) DCTS
F-01223 WISEWOMAN Case Management DPH

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Last Revised: March 26, 2019