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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-10127S Medicaid Purchase Plan (MAPP) - Work Requirement Exemption, Spanish DMS Spanish 12/2023 PDF No
F-01307 Medicaid Purchase Plan (MAPP) Eligibility Worksheet DMS English 08/2020 PDF No
F-01317 Medicaid Purchase Plan (MAPP) Impairment Related Work Expense (IRWE) Worksheet DMS English 07/2014 PDF No
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS English 06/2023 PDF No
F-10121H Medicaid Purchase Plan (MAPP) Independence Account Registration, Hmong DMS Hmong 06/2023 PDF No
F-10121S Medicaid Purchase Plan (MAPP) Independence Account Registration, Spanish DMS Spanish 06/2023 PDF No
F-01318 Medicaid Purchase Plan (MAPP) Medicaid and Remedial Expenses (MRE) Worksheet DMS English 07/2014 PDF No
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS English 07/2008 PDF No
F-01316 Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet DMS English 08/2020 PDF No
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS English 07/2008 PDF No
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions DMS English 07/2008 PDF No
F-00332 Medicaid Purchase Plan Premium Information / Payment DMS English 08/2020 PDF No
F-00332S Medicaid Purchase Plan Premium Information / Payment, Spanish DMS Spanish 08/2020 PDF No
F-10106S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice, Spanish DMS Spanish 07/2008 PDF No
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DMS English 07/2008 PDF No
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice DMS English 07/2008 PDF No
F-10107S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice, Spanish DMS Spanish 07/2008 PDF No
F-03084A Medicaid Standards for Certified 1-2 Bed Adult Family Homes Annual Certification Review: Evidentiary Document Checklist DMS English 01/2023 Word No
F-03084 Medicaid Standards for Certified 1-2 Bed Adult Family Homes Initial Certification Review: Evidentiary Document Checklist DMS English 01/2023 Word No
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH English 09/2019 PDF No
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH English 09/2019 Word No
F-20919 Medicaid Waiver Eligibility and Cost Sharing Worksheet DMS English 03/2017 PDF No
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS English 07/2020 HTML No
F-00295 Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs DMS English 01/2018 Word No
F-01598 Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents DMS English 08/2015 PDF No
F-01598H Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents, Hmong DMS Hmong 08/2015 PDF No
F-01598S Medical Exemption from Work Requirement for Able-Bodied Adults Without Dependents, Spanish DMS Spanish 08/2015 PDF No
F-01586 Medical Stockpile Access Request DPH English 03/2020 PDF No
F-01618 Medicare Counseling Client Services Agreement DPH English 04/2022 Word No
F-01618 Medicare Counseling Client Services Agreement DPH English 04/2022 HTML No
F-01618A Medicare Counseling Client Services Agreement, Instructions DPH English 04/2022 PDF No
F-01618LP Medicare Counseling Client Services Agreement, Large Print DPH English 04/2022 Word No
F-01618S Medicare Counseling Client Services Agreement, Spanish DPH Spanish 04/2022 Word No
F-02074 Medicare Other Coverage Discrepancy Report DMS English 04/2018 PDF No
F-02074 Medicare Other Coverage Discrepancy Report DMS English 04/2018 Word No
F-00855 Medication Therapy Management Case Management Software Requirements DMS English 08/2014 PDF No
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process DMS English 08/2013 PDF No
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-00251 Mental Health Block Grant Community Aids Allocation Report DCTS English 01/2023 HTML No
F-11090 Mental Health Day Treatment Functional Assessment DMS English 08/2015 Word No
F-11090 Mental Health Day Treatment Functional Assessment DMS English 08/2015 PDF No
F-11090A Mental Health Day Treatment Functional Assessment: Completion Instructions DMS English 08/2015 PDF No
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 DQA English 11/2011 PDF No
F-00512 Mental Health Day Treatment Program Initial Certification Application - DHS 61.75 DQA English 11/2011 Word No
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 DQA English 12/2011 Word No
F-00548 Mental Health Day Treatment Services for Children Program Application - DHS 40 DQA English 12/2011 PDF No
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA English 12/2011 PDF No
F-00547 Mental Health Inpatient Initial Certification Application - DHS 61.71 and 61.79 DQA English 12/2011 Word No
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA English 09/2020 Word No
F-02564 Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50 DQA English 09/2020 PDF No
Last revised December 8, 2023