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-10080 SeniorCare Authorization of Representative DMS
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License DPH
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding DMS
F-01442H IRIS Program Disenrollment Letter – Voluntary DMS
F-01332 Predispositional Investigation Report (PDI) DCTS
F-44016 Asbestos Occupant Protection Plan DPH
F-01765 TEFAP Food Pantry Self-Assessment Tool DPH
F-00634 County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-80477B Canteen Operations Balance Sheet - GAAP Basis DES
F-22637 Interagency Notification -Termination of Community Waiver Participation DMS
F-62601 Rights of Home Health Agency Patients DQA
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) DMS
F-00568 EMS Board Sub-Committee Appointment Application DPH
F-02483 PACE Program Enrollment DPH
F-11318 Enrollment Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-20987 Authorized Representative Designation Medicaid Community Waiver Programs DMS
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-62232 Hospice Contracts and Agreements Review DQA
F-25615 Supervised Release Rules DCTS
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 DQA
F-01601 DCTS Summary Line Item Budget DCTS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments (PDF, 55 KB) DPH
F-02167 Program Participation System (PPS) PORTAL Report Feedback DCTS
F-22491AL Consumer Survey – OBVI (Large Print) DPH
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS
F-00963 Children’s Long Term Support Reconciliation Packet DMS
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers DPH
F-00053 Notice of Intent to Submit an Application (ADRC) DPH
F-00642 Community Aids Reporting System (CARS) Expenditure Report DES
F-83263 Rehabilitation Review Application and Instructions OS
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-00334 Money Follows the Person (MFP) - Participant Reporting DMS
F-02022 Claims Audit Report for Managed Long-Term Care MCOs DMS
F-01275 IRIS Provider Board Member Disclosure DMS
F-01891 New Employment Reporting – FoodShare Employment and Training (FSET) Program DMS
F-20389 DCTS Program Performance Report DCTS
F-02520 Voluntarily Declining Benefits DMS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-80025 Forms / Publications Order OS
F-02470 IRIS Noncompliance Statement and Corrective Action Plan DMS
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) DPH
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire DQA
F-11018 Prior Authorization Request Form (PA/RF) DMS

Pages

Last Revised: March 26, 2019