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Official DHS Forms Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions. When you are searching for a document, enter the number or a portion of the title in the search box below. To narrow your search results even more, place quotation marks (" ") around search terms.

If you are looking for an informative document, visit our Informative Documents and Publications Library. If you need a file in another file format or can't find what you are looking for here, reach out to the Digital Communications Team at dhsfmorder@dhs.wisconsin.gov. You can typically expect a response within 1-2 business days.

Assigned Number Title Division Language Release Date File Type Available to Order
F-03069 LTHD COVID-19 Antigen Test Distribution Program DPH English 04/2023 HTML No
F-02188 Lyme Disease Case Worksheet DPH English 02/2022 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 Word No
F-12022A Managed Care Program Provider Appeal Instructions DMS English 02/2020 PDF No
F-02946 Management Evaluation Review (MER) Advocate Survey DMS English 02/2024 HTML No
F-02945 Management Evaluation Review (MER) Income Maintenance (IM) Staff Survey DMS English 02/2024 HTML No
F-00777 MAPT Vendor Related Allocation Formula DMS English 02/2017 Word No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH English 04/2015 PDF No
F-02531 Maternal Mortality Review Application DPH English 08/2019 PDF No
F-02655 Maternal Mortality Review Team Community Member Application DPH English 06/2020 PDF No
F-02707 Maternal Mortality Review Team Guest Pledge of Confidentiality DPH English 08/2020 PDF No
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH English 03/2019 Word No
F-03050 MC4JR Partnership Snapshot DPH English 06/2022 HTML No
F-02747 MCO Approval Request to DHS Performance Improvement Project (PIP) DMS English 11/2022 Word No
F-01590 MCO Letter: Notice of Change in Level of Care DMS English 02/2020 Word No
F-01590AR MCO Letter: Notice of Change in Level of Care, Arabic DMS Arabic 02/2020 Word No
F-01590CM MCO Letter: Notice of Change in Level of Care, Chinese (Simplified) DMS Chinese (Simplified) 02/2020 Word No
F-01590H MCO Letter: Notice of Change in Level of Care, Hmong DMS Hmong 02/2020 Word No
F-01590L MCO Letter: Notice of Change in Level of Care, Laotian DMS Laotian 02/2020 Word No
F-01590SE MCO Letter: Notice of Change in Level of Care, Serbo-Croatian DMS Serbian (Serbo-Croatian) 02/2020 Word No
F-01590SO MCO Letter: Notice of Change in Level of Care, Somali DMS Somali 02/2020 Word No
F-01590S MCO Letter: Notice of Change in Level of Care, Spanish DMS Spanish 02/2020 Word No
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate DMS English 01/2020 Word No
F-02466 MCO Quarterly Appeal Log DMS English 10/2023 Excel No
F-02466A MCO Quarterly Grievance Log DMS English 10/2023 Excel No
F-10112A Medicaid - Disability Application Addendum DMS English 11/2020 PDF No
F-10112AH Medicaid - Disability Application Addendum, Hmong DMS Hmong 11/2020 PDF No
F-10112AS Medicaid - Disability Application Addendum, Spanish DMS Spanish 11/2020 PDF No
F-20582 Medicaid - Katie Beckett Program Application DMS English 03/2023 Word No
F-20582H Medicaid - Katie Beckett Program Application, Hmong DMS Hmong 03/2023 Word No
F-20582S Medicaid - Katie Beckett Program Application, Spanish DMS Spanish 03/2023 Word No
F-20582B Medicaid - Katie Beckett Program Recertification DMS English 03/2023 Word No
F-20582BH Medicaid - Katie Beckett Program Recertification, Hmong DMS Hmong 03/2023 Word No
F-20582BS Medicaid - Katie Beckett Program Recertification, Spanish DMS Spanish 03/2023 Word No
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS English 06/2018 PDF No
F-10151H Medicaid / BadgerCare Plus Fair Hearing Information, Hmong DMS Hmong 06/2018 PDF No
F-10151S Medicaid / BadgerCare Plus Fair Hearing Information, Spanish DMS Spanish 06/2018 PDF No
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS English 02/2014 PDF No
F-01381 Medicaid Administrative Pass-Through (MAPT) Time Summary DMS English 10/2014 Excel No
F-10093S Medicaid and BadgerCare Overpayment Notice, Spanish DMS Spanish 09/2019 PDF No
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DMS English 09/2019 PDF No
F-10093S Medicaid and BadgerCare Plus Overpayment Notice, Spanish DMS Spanish 09/2019 Word No
F-10191 Medicaid Annuity Beneficiary Designation DMS English 01/2009 PDF No
F-10192 Medicaid Annuity Information - Disclosure DMS English 01/2009 PDF No
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS English 07/2015 PDF No
F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse, Spanish DMS Spanish 07/2008 PDF No
F-10137 Medicaid Change Report DMS English 06/2023 PDF No
F-10137DA Medicaid Change Report, Dari DMS Dari (Afghan Persian) 06/2023 PDF No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised December 4, 2024