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 Division Other Location
F-20009 Complaint Report DCTS
F-19002 Request to Reduce QUEST Card Balance DMS
F-16104 Local Agency Customer Feedback DMS
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request DMS
F-16076 FoodShare Six-Month Report and Instructions DMS
F-16073 FoodShare Wisconsin Nonfinancial Worksheet DMS
F-16066 FoodShare Wisconsin Income Change Report DMS
F-16050 Agency Position on the State Quality Control (QC) Finding DMS
F-16039 Waiver of Administrative Disqualification Hearing DMS
F-16038 Administrative Disqualification Hearing Notice DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16033 FoodShare Worksheet DMS
F-16031 Student Aid and Expense Worksheet DMS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-16029 FoodShare Wisconsin Repayment Agreement DMS
F-16028 Notice of FoodShare Overissuance DMS
F-16026 Prosecution Diversion Agreement DMS
F-16025 Disqualification Consent Agreement DMS
F-16024 FoodShare Notice of Disqualification DMS
F-16023 Striker Evaluation DMS
F-16022 Social Security Number Referral DMS
F-16021 Student Financial Aid Report DMS
F-16019B FoodShare Wisconsin Registration Packet DMS
F-16019A FoodShare Wisconsin Registration DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-16014 Notice of Program Violation DMS
F-16011 Quality Assurance (QA) Sample Checklist DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) DMS
F-13509 Wisconsin Well Woman Program Provider Certification OIG
F-13470 Claim Form Attachment Cover Page DMS
F-13393 Trading Partner 835 Designation DMS
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization DMS
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request DMS
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request DMS
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request DMS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request DMS
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS

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Last Revised: March 26, 2019