Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Number Title Division Other Locationsort ascending
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-44024A WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women DPH
F-02109D CBRF – New Provider Licensure Application Checklist DQA
F-05282 Wisconsin Divorce Certificate Application DPH
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP) DMS
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances DQA
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing DPH
F-02403 Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment DPH
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH
F-21225A Program Participation System (PPS): B-3 Module DMS
F-80142 Collections Delegation Application DES
F-02475 Hand Hygiene Observations DPH
F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS
F-62494 Health Care Facility Construction Documentation Checklist DQA
F-02605A HCBS Settings Rule: Heightened Scrutiny Settings Review – Evidentiary Document Checklist DMS
F-00805 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents DMS
F-60795 Community Based Residential Facility (CBRF) Fire Inspection DQA
F-01601C DCTS Summary Line item Budget: Condensed DCTS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-01749 Prior Authorization Drug Attachment for Hypoglycemics, Insulin – Long-Acting DMS
F-00533 Partnership Programs — Enrollment DPH
F-45007 Certificate of Disposition of Materials DPH
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-01588 Application for Available Beds DMS
F-43009 Diabetes Emergency Action Plan DPH
F-02491 FoodShare Buy and Make Food Separately DMS
F-01812D Current Occupancy Test Worksheet for Billing Medicaid Bed-Hold Days DMS
F-02324 Wisconsin’s American Sign Language Interpreter, SSP and CART Directory Sign-Up and/or Change Request DPH
F-00367G Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 4 - 6 Years DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-25180 Order of Discharge Upon Expiration of Commitment DCTS
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice DMS
F-00989-Packet Individualized Family Service Plan (IFSP) Packet DMS
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications DCTS
F-02296 Medicaid Fraud Control Elder Abuse Unit Referral OIG
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS
F-62657 Home Health Agency Contract Review Worksheet DQA
F-01997 Children's Community Options (CCOP) Reconciliation Packet DMS
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH
F-62319 Hospice Volunteer Program Review DQA
F-01454H IRIS Program Withdrawal Letter – Conflict of Withdrawal DMS
F-11130 Tribal and Out-of-State Federally Qualified Health Center Interim Report DMS
F-01766 The Emergency Food Assistance Program (TEFAP) - Shelter Review DPH
F-47463B EMT - Basic Operational Plan Components DPH
F-02614 Fraud Prevention and Investigation Program (FPIP) Fraud Year Contact Information OIG

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Last Revised: March 23, 2021