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 ascending Title Other Location
F-20822 County Review of Nursing Home, IMD or ICF / IID Referrals
F-20818 Certification for SSI-E Exceptional Expense Supplement
F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses
F-20817 Assessment Worksheet for Natural Residential Setting
F-20812 SSI-E Natural Residential Setting Application Checklist
F-20691 Request for Exemption - Intoxicated Driver Program (IDP), Employment of Individuals with Lesser Qualifications
F-20582 Medicaid – Katie Beckett Program Application and Recertification
F-20572 Request for State Public Funding for Non-Residents
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request
F-20465 Declaration of Income
F-20448 Request for Medicaid Administrative Funds - Staff Position
F-20445A Individual Service Plan – Individual Outcomes
F-20445 Individual Service Plan – Children’s Long-Term Support Programs
F-20441Ai Adult-At-Risk Abuse, Neglect, and/or Exploitation Valid Values
F-20441A Adult-At-Risk Abuse, Neglect, and/or Exploitation Data Collection
F-20389 DCTS Program Performance Report
F-20224 Office for the Blind and Visually Impaired Assessment / Plan / Evaluation
F-20009 Complaint Report
F-19002 Request to Reduce QUEST Card Balance
F-16106A FoodShare Affidavit of Lost Income or Costs from a Disaster – Wisconsin
F-16104 Local Agency Customer Feedback
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request
F-16076 FoodShare Six-Month Report and Instructions
F-16073 FoodShare Wisconsin Nonfinancial Worksheet
F-16066 FoodShare Wisconsin Income Change Report
F-16050 Agency Position on the State Quality Control (QC) Finding
F-16039 Waiver of Administrative Disqualification Hearing
F-16038 Administrative Disqualification Hearing Notice
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065)
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S)
F-16034 Self-Employment Income Worksheet - Corporation
F-16033 FoodShare Worksheet
F-16031 Student Aid and Expense Worksheet
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator
F-16029 FoodShare Wisconsin Repayment Agreement
F-16028 Notice of FoodShare Overissuance
F-16026 Prosecution Diversion Agreement
F-16025 Disqualification Consent Agreement
F-16024 FoodShare Notice of Disqualification
F-16023 Striker Evaluation
F-16022 Social Security Number Referral
F-16021 Student Financial Aid Report
F-16019B FoodShare Wisconsin Registration Packet
F-16019A FoodShare Wisconsin Registration
F-16015 Notice of Approval of Benefits/Positive Change in Benefits
F-16014 Notice of Program Violation
F-16011 Quality Assurance (QA) Sample Checklist
F-16006 FoodShare Wisconsin Change Report
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits
F-16001 Notice of Denial of Benefits/Negative Change in Benefits

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Last Revised: May 22, 2018