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Data Collection (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 form, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-00943 Exhibit II - Tribal Work Plan OS English 05/2023 Word No
F-01234 Explanation of Medical Benefits DMS English 04/2018 Word No
F-01234 Explanation of Medical Benefits DMS English 04/2018 PDF No
F-02296 F-02296, Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with HMOs, MCOs, and IRIS OIG English 10/2019 Word No
F-02296B F-02296B, Medicaid Fraud Control Elder Abuse Unit Referral Feedback: Used in Partnership with HMOs, MCOs, and IRIS OIG English 10/2019 Word No
F-02296C F-02296C, Medicaid Fraud Control Elder Abuse Unit Referral: Overpayment Recovery OIG English 02/2020 Word No
F-02296I F-02296i,Instructions: Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with HMOs and MCOs OIG English 10/2019 PDF No
F-02296II F-02296ii,Instructions: Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with IRIS OIG English 10/2019 PDF No
F-11023 F-11023, F-11023B, and F-11023C: Cost Report for Provider-Based Rural Health Clinics DMS English 06/2024 Excel No
F-11023BI F-11023BI: Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Instructions DMS English 06/2024 PDF No
F-11023I F-11023I: Cost Report for Provider-Based Rural Health Clinics Instructions DMS English 06/2024 PDF No
F-02500 Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care DPH English 12/2020 Word No
F-03215 Facility Request For DHS Connect Viewer Access DCTS English 08/2023 Word No
F-03146 Facility Request for DHS Connect Viewer Access DCTS English 05/2023 Word No
F-05103 Facts About Your Child's Birth Certificate DPH English 03/2024 PDF No
F-05103H Facts About Your Child's Birth Certificate, Hmong DPH Hmong 03/2024 PDF No
F-05103S Facts About Your Child's Birth Certificate, Spanish DPH Spanish 03/2024 PDF No
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DMS English 12/2018 Word No
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH English 02/2024 Word No
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions (DocuSign) DPH English 02/2024 HTML No
F-00221LP Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions (Large Print) DPH English 02/2024 Word No
F-00221AR Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Arabic DPH Arabic 02/2024 PDF No
F-00221CM Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Chinese (Simplified) DPH Chinese (Simplified) 02/2024 Word No
F-00221H Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Hmong DPH Hmong 02/2024 Word No
F-00221L Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Laotian DPH Laotian 02/2024 Word No
F-00221R Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Russian DPH Russian 02/2024 Word No
F-00221SE Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Serbo-Croatian DPH Serbian (Serbo-Croatian) 02/2024 Word No
F-00221SO Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Somali DPH Somali 02/2024 Word No
F-00221S Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions, Spanish DPH Spanish 02/2024 Word No
F-02558 Family Care Member County Notification DMS English 09/2020 Word No
F-02738 Family Care Partnership Appeal Decision Letter DMS English 10/2020 Word No
F-02739 Family Care Partnership Letter about Your Right to Make a Fast Complaint DMS English 10/2020 Word No
F-00046 Family Care Program: Enrollment DPH English 02/2024 Word No
F-00046 Family Care Program: Enrollment (DocuSign) DPH English 02/2024 HTML No
F-00046LP Family Care Program: Enrollment (Large Print) DPH English 02/2024 Word No
F-00046AR Family Care Program: Enrollment, Arabic DPH Arabic 02/2024 PDF No
F-00046CM Family Care Program: Enrollment, Chinese (Simplified) DPH Chinese (Simplified) 02/2024 Word No
F-00046H Family Care Program: Enrollment, Hmong DPH Hmong 02/2024 Word No
F-00046L Family Care Program: Enrollment, Laotian DPH Laotian 02/2024 Word No
F-00046R Family Care Program: Enrollment, Russian DPH Russian 02/2024 Word No
F-00046SE Family Care Program: Enrollment, Serbo-Croatian DPH Serbian (Serbo-Croatian) 02/2024 Word No
F-00046SO Family Care Program: Enrollment, Somali DPH Somali 02/2024 Word No
F-00046S Family Care Program: Enrollment, Spanish DPH Spanish 02/2024 Word No
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting DMS English 05/2024 Excel No
F-02403 Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment DPH English 10/2024 Word No
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH English 05/2023 Word No
F-02720 Family Caregiver Support Program Initial Evaluation DPH English 03/2021 Word No
F-02720 Family Caregiver Support Program Initial Evaluation, Spanish DPH Spanish 03/2021 Word No
F-02720A Family Caregiver Support Program Post Evaluation DPH English 03/2021 Word No
F-02720AS Family Caregiver Support Program Post Evaluation, Spanish DPH Spanish 03/2021 Word No

Glossary

 
Last revised August 26, 2024