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-01601 DCTS Summary Line Item Budget DCTS
F-01947 IRIS Participant Education Manual: Acknowledgement DMS
F-01058 Important Notice About the Wisconsin Chronic Renal Disease Program Drug Benefit DMS
F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments (PDF, 55 KB) DPH
F-11271 Personal Care Provider Addendum DMS
F-22491AL Consumer Survey – OBVI (Large Print) 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-00855 Medication Therapy Management Case Management Software Requirements DMS
F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers DPH
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS
F-00642 Community Aids Reporting System (CARS) Expenditure Report DES
F-02108 Adult Family Home – Applicant Compliance Statement DQA
F-00567 Emergency Medical Services Complaint DPH
F-83263 Rehabilitation Review Application and Instructions OS
F02029 Application for Wisconsin Certified Parent Peer Specialist Curriculum Trainer DCTS
F-00407 Financial Records Request DMS
F-80025 Forms / Publications Order OS
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline DMS
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments DPH
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) DPH
F-02558 Family Care Member Out-of-County Notification DMS
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment DMS
F-62501 Laboratory Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-01679 Communicable Disease / Tuberculosis Screening Questionnaire DQA
F-02487 Wisconsin Immunization Registry (WIR) Record Release Authorization DPH
F-00012 Community Based Residential Facility Completion Documents DQA
F-01159 Commercial Other Coverage Discrepancy Report DMS
F-62028 Report of Hours Worked - Nurse Aide / Night DQA
F-00412 Third Party Administration (TPA) Children's Medicaid Waivers Provider Billing and Service Information DMS
F-80112 Vendor Validation DES
F-01578A IRIS SharePoint - Request for User Setup DMS
F-00309 Medicaid Provider Report DQA
F-22491 Consumer Report and Survey - OBVI DPH
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment DMS
F-62502 Analyst Application to Perform Alcohol, Controlled Substance, and Controlled Substance Analog Testing DQA
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DMS
F-16050 Agency Position on the State Quality Control (QC) Finding DMS
F-01681 Comprehensive Community Services (CCS) Technical Assistance Survey DCTS
F-02488 IRIS Monthly Rate of Service (MROS) Discrepancy Resolution DMS
F-00014 Ceiling Closure Inspection Checklist DQA
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-62030 Resident Census DQA
F-13148 HIPAA Privacy Access Request DMS
F-01569 IRIS Consultant Agency (ICA) Transfer Checklist DMS
F-02324 Wisconsin’s American Sign Language Interpreter, SSP and CART Directory Sign-Up and/or Change Request DPH
F-01002 HealthCheck Individual Health History DMS
F-11090 Mental Health Day Treatment Functional Assessment DMS

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Last Revised: March 26, 2019