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 Sort descending	Division	Language	Release Date	File Type	Available to Order
F-10137PA	Medicaid Change Report, Pashto	DMS	Pashto	06/2023	PDF	No
F-10137S	Medicaid Change Report, Spanish	DMS	Spanish	06/2023	PDF	No
F-01298	Medicaid Deductible Worksheet	DMS	English	07/2014	PDF	No
F-10112	Medicaid Disability Application	DMS	English	04/2024	PDF	Yes
F-10112H	Medicaid Disability Application, Hmong	DMS	Hmong	04/2024	PDF	No
F-10112S	Medicaid Disability Application, Spanish	DMS	Spanish	04/2024	PDF	No
F-10114	Medicaid Disability Redetermination Report	DMS	English	10/2023	PDF	No
F-01297	Medicaid Institution Determination Worksheet	DMS	English	07/2014	PDF	No
F-10190	Medicaid Issuer of Annuity - Notice of Obligation	DMS	English	01/2009	PDF	No
F-10108	Medicaid Manual Notice for Cost of Care Contribution	DMS	English	07/2008	PDF	No
F-10108A	Medicaid Manual Notice for Cost of Care Contribution Instructions	DMS	English	07/2008	PDF	No
F-10098	Medicaid Member Asset Allocation	DMS	English	10/2022	PDF	No
F-10098H	Medicaid Member Asset Allocation, Hmong	DMS	Hmong	10/2022	PDF	No
F-10098S	Medicaid Member Asset Allocation, Spanish	DMS	Spanish	10/2022	PDF	No
F-10130	Medicaid Presumptive Disability	DMS	English	07/2024	PDF	No
F-00309	Medicaid Provider Report	DQA	English	09/2018	PDF	No
F-00309	Medicaid Provider Report	DQA	English	09/2018	Word	No
F-10127	Medicaid Purchase Plan (MAPP) - Work Requirement Exemption	DMS	English	12/2023	PDF	No
F-10127H	Medicaid Purchase Plan (MAPP) - Work Requirement Exemption, Hmong	DMS	Hmong	12/2023	PDF	No
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-00332	Medicaid Purchase Plan Premium Information / Payment	DMS	English	09/2024	PDF	No
F-00332S	Medicaid Purchase Plan Premium Information / Payment, Spanish	DMS	Spanish	09/2024	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-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	HTML	No
F-01618	Medicare Counseling Client Services Agreement	DPH	English	04/2022	Word	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

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