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 Numbersort descending Title Division Other Location
F-01210 IRIS Budget Amendment Request DMS
F-01210A IRIS Budget Amendment Provider Quote Comparison DMS
F-01210B Budget Amendment Annual Verification (BAAV) Request DMS
F-01212 Grievance - IRIS Program DMS
F-01213 Accessibility Assessment Request DMS
F-01216 Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Regional Model Supplemental Application DHS 36 DQA
F-01218 WISEWOMAN Client Consent DPH
F-01219 WISEWOMAN Health History Assessment DPH
F-01219-pckt WISEWOMAN Integrated Office Visit Assessment Packet DPH
F-01220 WISEWOMAN Healthy Lifestyle Assessment DPH
F-01221 WISEWOMAN Screening Activity DPH
F-01222 WISEWOMAN Diagnostic and Hypertension Management Referral DPH
F-01223 WISEWOMAN Case Management DPH
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-01229 WISEWOMAN Provider Assurances and Training Checklist DPH
F-01234 Explanation of Medical Benefits DMS
F-01238 Consent to Release Medical Information - Referral to a Regional Center for Children & Youth with Special Health Care Needs DPH
F-01240 IRIS Critical Incident Reconciliation DMS
F-01246 Background Information Disclosure Addendum—IRIS DMS
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents DMS
F-01252 FoodShare Employment and Training (FSET) - Initial Appointment DMS
F-01253 FoodShare Employment and Training (FSET) - Appointment Final Notice DMS
F-01254 FoodShare Employment and Training (FSET) - Employment Plan (EP) Appointment DMS
F-01255 FoodShare Employment and Training (FSET) - Job Club Appointment DMS
F-01256 FoodShare Employment and Training (FSET) - Discuss FSET Participation DMS
F-01257 FoodShare Employment and Training (FSET) - Workshop Appointment DMS
F-01258 IRIS Self-Directed Personal Care (SDPC) Disclosure Statement DMS
F-01261 Fraud Statement - IRIS Program DMS
F-01264 Service Fund Application for Reimbursement DPH
F-01268 Application to Conduct Intoxicated Driver Assessments, Tribal Treatment Facility DCTS
F-01270 Comprehensive Community Services Non-Traditional Approval DMS
F-01275 IRIS Provider Board Member Disclosure DMS
F-01275A IRIS Provider Executive Staff Disclosure DMS
F-01278 Program Participation System (PPS) Employment Questions DMS
F-01279 Program Participation System (PPS) Employment Interview DMS
F-01282 Monthly Enrollment Discrepancy Report Template - Model DMS
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting DMS
F-01293 Participant Fiscal Employer Agent (FEA) Selection DMS
F-01293A Participant Fiscal Employer Agent (FEA) – Change Request DMS
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter DMS
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter DMS
F-01293D Participant Fiscal Employer Agent (FEA) – Transfer Checklist DMS
F-01302 Weekly Driver's Vehicle Inspection Report DMS
F-01309 IRIS Program Orientation and Enrollment Checklist DMS
F-01310 IRIS Program Conflict of Interest Disclosure – Provider DMS
F-01310A IRIS Program Conflict of Interest Disclosure - Participant DMS
F-01312 IRIS Provider Application DMS
F-01313 Register to Reschedule Lead (Pb) Certification Exam DPH
F-01314 IRIS Program Employment Checklist DMS


Last Revised: March 26, 2019