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-13393 Trading Partner 835 Designation DMS
F-01710 Home Health Agency Initial Licensure Checklist DQA
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-62027 Report of Hours Worked - Registered Nurse / Night DQA
F-02109C CBRF – New Provider Licensure Application DQA
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis DMS
F-01579 Wisconsin eWIC Cash Register System Survey DPH
F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-00634A Types and Locations of Early Intervention Records Birth to 3 Program DMS
F-62546 Corporate Guardianship Program Annual Report DQA
F-00043 Communication to Local Educational Agency Regarding Child Referral DMS
F-00891 Wisconsin Caregiver Program Abuse and Neglect Prevention Training DVD Request DQA
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-00565 County Performance Plan (CPP) DMS
F-44024A WIC Request for Medical Food: Pregnant, Breastfeeding, and Nonbreastfeeding Postpartum Women DPH
F-10141 Wisconsin Funeral and Cemetery Aids Program Application DMS
F-01394 Virginia Graeme Baker Act – Drain Cover Replacement Log DPH
F-00397 Consent to Use and Disclose Information for Multiple Registration/Continuity of Care DCTS
F-40074 Annual Physical Activity Record DPH
F-02110 RCAC: Applicant Compliance Statement DQA
F-00276 Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records DQA
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP) DPH
F-02026 Ethnicity and Race Selection DPH
F-01261 Fraud Statement - IRIS Program DMS
F-62692 Feeding Assistant Training Program Primary Instructor Application DQA
F-02639 Time and Task Pretest DPH
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation DPH
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-62440 Report of Hours Worked - Other Direct Care Nurse Aide / Day DQA
F-02536 Nursing Home: Waiver or Variance Request DQA
F-01619 OARS Welcome Letter DCTS
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-47482 EMT Training Center Certification Application DPH
F-11130 Federally Qualified Health Center Interim Report DMS
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter DMS
F-00759 Business Associate Agreement: With Contract DES
F-45007 Certificate of Disposition of Materials DPH
F-21353 Children's Long-Term Support Waiver High-Cost Request DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting DMS
F-00519 Community Substance Abuse Services (CSAS) Medically Managed Residential Detoxification Service Initial Certification Application - DHS 75.07 DQA
F-00103 Wisconsin Blood Lead Registry User Security and Confidentiality Agreement DPH
F-01204A Letter – IRIS Program Notice of Action – Denial DMS
F-00367F Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 36 Months - 4 Years DMS
F-01924 Public Comment on Rulemaking Project OLC
F-80883 CARS Contract Adjustment - Extensions and Moves DES

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Last Revised: March 26, 2019