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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-80983AH Instructions - Completing the Civil Rights Complaint, Hmong OLC Hmong 04/2024 PDF No
F-80983AS Instructions - Completing the Civil Rights Complaint, Spanish OLC Spanish 04/2024 PDF No
F-20582I Instructions for Completing the Application for Katie Beckett Medicaid DMS English 03/2023 PDF No
F-20582IH Instructions for Completing the Application for Katie Beckett Medicaid, Hmong DMS Hmong 03/2023 PDF No
F-20582IS Instructions for Completing the Application for Katie Beckett Medicaid, Spanish DMS Spanish 03/2023 PDF No
F-00989I Instructions for Completing Wisconsin's Individualized Family Service Plan (IFSP) DMS English 03/2017 PDF No
F-00950I Instructions for Coverage Decision Letter DMS English 01/2024 PDF No
F-03112I Instructions for Logging HMO Appeals DMS English 01/2024 PDF No
F-02466I Instructions for Logging MCO Appeals DMS English 12/2022 PDF No
F-02466AI Instructions for Logging MCO Grievances DMS English 12/2022 PDF No
F-00232I Instructions for Notice of Adverse Benefit Determination (Notice of Action) DMS English 12/2021 PDF No
F-62022A Instructions for Report of Hours Worked and Resident Census Forms DQA English 02/2009 PDF No
F-62022A Instructions for Report of Hours Worked and Resident Census Forms DQA English 02/2009 Word No
F-00539 Instructions for the County Waiver Agency Support and Service Coordination (SSC) Rates DMS English 09/2019 PDF No
F-00202I Instructions – Individual Service Plan – Community Recovery Services (CRS) DCTS English 08/2016 PDF No
F-00107 Instructions, Self-Employment Income Report DMS English 06/2019 PDF No
F-00107ACM Instructions, Self-Employment Income Report, Chinese (Simplified) DMS Chinese (Simplified) 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-00634 Instructions-County Birth to 3 Program Annual Notification of Parental Rights Regarding Records DMS English 02/2017 PDF No
F-00634 Instructions-County Birth to 3 Program Annual Notification of Parental Rights Regarding Records, Spanish DMS Spanish 02/2017 PDF No
F-02717A Instructions: Electronic Visit Verification (EVV) Live-in Worker Identification DMS English 04/2023 PDF No
F-02717AH Instructions: Electronic Visit Verification (EVV) Live-in Worker Identification, Hmong DMS Hmong 04/2023 PDF No
F-02717AS Instructions: Electronic Visit Verification (EVV) Live-in Worker Identification, Spanish DMS Spanish 04/2023 PDF No
F-01234A Instructions: Explanation of Medical Benefits DMS English 11/2023 PDF No
F-16030B Instructions: FoodShare Wisconsin Overpayment Calculator DMS English 01/2018 PDF No
F-02382I Instructions: HCBS Heightened Scrutiny Residential Provider Evidentiary Worksheet DMS English 10/2020 PDF No
F-22540 Instructions: Human Service Revenue Reporting - Expenditures by Revenue Source for Human Service Programs OPIB English 05/2019 PDF No
F-10110A Instructions: Medicaid/BadgerCare Plus Eligibility Certification DMS English 01/2018 HTML No
F-02074A Instructions: Medicare Other Coverage Discrepancy Report DMS English 04/2018 PDF No
F-11010A Instructions: Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS English 01/2018 PDF No
F-11008A Instructions: Prior Authorization / Therapy Attachment (PA/TA) DMS English 07/2024 PDF No
F-01248A Instructions: Prior Authorization Drug Attachment for Hepatitis C Agents Renewal DMS English 08/2016 PDF No
F-22637 Interagency Notification -Termination of Community Waiver Participation DMS English 03/2017 PDF No
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS English 07/2008 PDF No
F-42010 Interjurisdictional Tuberculosis Notification DPH English 03/2003 PDF No
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up DPH English 03/2003 PDF No
F-47463D Intermediate Operational Plan Components DPH English 06/2012 PDF No
F-47463C Intermediate Technician Operational Plan Components DPH English 06/2012 PDF No
F-03010 Intoxicated Driver Program Assessor Training Application DCTS English 03/2022 HTML No
F-01761 Intoxicated Driver Program Self-Evaluation DCTS English 09/2016 Word No
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS English 08/2024 Word No
F-02961 Introduction to Community Recovery Services Presentation Evaluation Survey DCTS English 02/2022 HTML No
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH English 02/2024 Word No
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization (DocuSign) DPH English 02/2024 HTML No
F-00075LP IRIS (Include, Respect, I Self-Direct) Authorization (Large Print) DPH English 02/2024 Word No
F-00075AR IRIS (Include, Respect, I Self-Direct) Authorization, Arabic DPH Arabic 02/2024 PDF No
F-00075CM IRIS (Include, Respect, I Self-Direct) Authorization, Chinese (Simplified) DPH Chinese (Simplified) 02/2024 Word No
F-00075H IRIS (Include, Respect, I Self-Direct) Authorization, Hmong DPH Hmong 02/2024 Word No
F-00075L IRIS (Include, Respect, I Self-Direct) Authorization, Laotian DPH Laotian 02/2024 Word No

Glossary

 
Last revised August 26, 2024