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 Other Locationsort descending
F-02371 Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists
F-40054A Confidential Birth Defects Registry – Request to Remove Identifiers
F-80883 CARS Contract Adjustment - Extensions and Moves
F-02140 Urgent Services Agreement
F-00051 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Varicella, Meningococcal Conjugate (MCV4) Vaccine(s)
F-00464 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Recertification Application - DHS 75.06
F-62648A Personal Care Agency Sample Selection
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E)
F-00315C Prior Notice and Consent for Evaluation and Assessment
F-62318 Hospice Quality Assessment and Performance Improvement Review
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-10190 Medicaid Issuer of Annuity - Notice of Obligation
F-10098 Medicaid Member Asset Allocation Notice
F-01346 Behavior Monitoring Record-Model
F-01936 Wisconsin EMS Intermediate Training Record - Intermediate Refresher Requirements
F-01716 Calculating Expenses for a CLTS Foster Home Using the Uniform Foster Care Brochure
F-00171 Lead Company Application
F-01601 DCTS Summary Line Item Budget
F-44014 Lead-Free Inspection Affidavit of Property Owner
F-22491AL Consumer Survey – OBVI (Large Print)
F-40092 Physical Activity Zone
F-22637 Interagency Notification -Termination of Community Waiver Participation
F-20818 Certification for SSI-E Exceptional Expense Supplement
F-01162 Certification of Emergency for Non-U.S. Citizens
F-21059 Variance Request for Institution Respite
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election
F-01398 WISEWoman Client Home Blood Pressure Monitoring Agreement
F-01999A 2020 Retired Senior Volunteer Program: State Match Funding Application
F-00754 Wisconsin Civil Service Request for Examination Accommodations
F-01221 WISEWOMAN Screening Activity
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-00543A File Review Checklist
F-80459 Client Account Balance Report
F-00020 Drug Addition Review Request
F-16001 Notice of Denial of Benefits/Negative Change in Benefits
F-62588 Feeding Assistant Training Program Application
F-62158 Living Unit Direct Care Staff Report - Night Shift
F-11042 Prior Authorization Amendment Request
F-10150B Your Rights and Responsibilities for FoodShare
F-60945 Adult Family Home Initial Licensure Application
F-00381 Outpatient Mental Health Clinic Certification Withdrawal Checklist
F-01991 ACCESS Application Cover Sheet – Milwaukee Enrollment Services (MilES)
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter
F-01642 OBVI Orientation and Mobility Screening
F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels
F-01319C IRIS Program – Denial of Enrollment Letter
F-43013 Diabetes Medical Management Plan
F-01309 IRIS Program Orientation and Enrollment Checklist
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement


Last Revised: May 22, 2018