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Forms: Numeric List - OIG
Office of the Inspector General

This numeric list contains forms that are available from this site.  A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms. Microsoft Word - Fillable or Excel forms, can be filled in, saved, and transmitted electronically.  You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Key word explanations for Form Type and Other Location columns.
Division Prefix / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
OIG F-00212 ForwardHealth - Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment(PDF, 96 KB) PDF None English
OIG F-00212 ForwardHealth - Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment Word None English
OIG F-00212A ForwardHealth - Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment Completion Insttructions (PDF, 46 KB) PDF None English
OIG F-00341 Community Recovery Services Terms of Reimbursement (PDF, 34 KB) PDF None English
OIG F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) PDF None English
OIG F-00577 Report Fraud ASP None English
HCF-01070 F-01070 Ambulance Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01072 F-01072 Ambulatory Surgical Center Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01074 F-01074 Anesthetist Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01082 F-01082 Audiology Terms of Reimbursement (PDF, 53 KB) PDF None English
HCF-01083 F-01083 Hearing Instrument Specialist Terms of Reimbursement (PDF, 52 KB) PDF None English
HCF-01084 F-01084 Speech - Language Pathology Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01086 F-01086 Case Management Terms of Reimbursement (PDF, 43 KB) PDF None English
HCF-01088 F-01088 Chiropractor Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01092 F-01092 Dental - Dental Hygienists Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01094 F-01094 Free Standing End-Stage Renal Disease Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01095 F-01095 Hospital Affiliated End-Stage Renal Disease Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01099 F-01099 Family Planning Clinic Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01108 F-01108 Federally Qulified Health Center Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01113 F-01113 HealthCheck Other Services Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01114 F-01114 HealthCheck Screener and Case Management Provider Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01121 F-01121 Home Health Agency Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01125 F-01125 Hospice Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01127 F-01127 Border Status Hospitals Terms of Reimbursement (PDF, 38 KB) PDF None English
HCF-01128 F-01128 Hospital Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01130 F-01130 Laboratories Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01131 F-01131 Blood Banks Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01176 F-01176 ForwardHealth Prior Authorization Fax Cover Sheet (PDF, 16 KB) PDF None English
HCF-01176 F-01176 ForwardHealth Prior Authorization Fax Cover Sheet Word None English
HCF-01501 F-01501 Private Duty Nursing to Ventilator-Dependent Members Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01502 F-01502 Private Duty Nursing Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01504 F-01504 Nurse Midwife Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01506 F-01506 Medical Supply and Equipment Vendor Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01507 F-01507 Mental Health / Substance Abuse Services Terms of Reimbursement (PDF, 45 KB) PDF None English
HCF-01509 F-01509 Nurse Practitioner Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01512 F-01512 Occupational Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01514 F-01514 Optometrist / Optician Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01516 F-01516 Personal Care Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01518 F-01518 Pharmacy Terms of Reimbursement (PDF, 49 KB) PDF None English
HCF-01520 F-01520 Physical Therapy Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01523 F-01523 Physician and Physician Assistant Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01525 F-01525 Podiatrist Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01527 F-01527 Portable X-Ray Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01529 F-01529 PreNatal Care Coordination Agency Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01531 F-01531 Rehabilitation Agency Terms of Reimbursement (PDF, 42 KB) PDF None English
HCF-01533 F-01533 Rural Health Clinic Terms of Reimbursement (PDF, 44 KB) PDF None English
HCF-01535 F-01535 School-Based Services Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01537 F-01537 Specialized Medical Vehicle Terms of Reimbursement (PDF, 41 KB) PDF None English
HCF-01539 F-01539 Wisconsin Chronic Disease Program Provider Enrollment (PDF, 354 KB) PDF None English
HCF-01540 F-01540 Wisconsin Chronic Disease Program Provider Application and Instructions PDF None English
HCF-01541 F-01541 Wisconsin Chronic Disease Program Provider Agreement and Acknowledgement of Terms of Participation (Standard for Individual and Clinic / Group / Agency Providers) PDF None English
HCF-10172 F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) PDF None English
HCF-11001 F-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet (PDF, 94 KB) PDF None English
HCF-11001 F-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet Word None English
HCF-11001A F-11001A Wisconsin Medicaid Out-of-State Provider Data Sheet Completion Instructions (PDF, 53 KB) PDF None English
HCF-11002 F-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet (PDF, 80 KB) PDF None English
HCF-11002 F-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet Word None English
HCF-11002A F-11002A Wisconsin Medicaid In-State Emergency Provider Data Sheet Completion Instructions (PDF, 46 KB) PDF None English
HCF-11008 F-11008 ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) (PDF, 83 KB) PDF None English
HCF-11008 F-11008 ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) Word None English
HCF-11008A F-11008A ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) Completion Instructions (PDF, 98 KB) PDF None English
HCF-11010 F-11010 ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format (PDF, 253 KB) PDF None English
HCF-11010 F-11010 ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format Word None English
HCF-11010A F-11010A ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Completion Instructions (PDF, 31 KB) PDF None English
HCF-11011 F-11011 ForwardHealth Prior Authorization / Birth to 3 Attachment (PA/B3) (PDF, 48 KB) PDF None English
HCF-11011 F-11011 ForwardHealth Prior Authorization / Birth to 3 Attachment (PA/B3) Word None English
HCF-11013 F-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet (PDF, 80 KB) PDF None English
HCF-11013 F-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet Word None English
HCF-11013A F-11013A Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet Completion Instructions (PDF, 44 KB) PDF None English
HCF-11014 F-11014 ForwardHealth Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services (PDF, 67 KB) PDF None English
HCF-11014 F-11014 ForwardHealth Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services Word None English
HCF-11016 F-11016 ForwardHealth Prior Authorization Physician Attachment (PA/PA) (PDF, 50 KB) PDF None English
HCF-11016 F-11016 ForwardHealth Prior Authorization Physician Attachment (PA/PA) Word None English
HCF-11016A F-11016A ForwardHealth Prior Authorization Physician Attachment (PA/PA) Completion Instructions (PDF, 22 KB) PDF None English
HCF-11018 F-11018 ForwardHealth Prior Authorization Request Form (PA/RF) (PDF, 148 KB) PDF None English
HCF-11018 F-11018 ForwardHealth Prior Authorization Request Form (PA/RF) Word None English
HCF-11019 F-11019 ForwardHealth Prior Authorization / Physician Otological Report (PA/POR) (PDF, 67 KB) PDF None English
HCF-11019 F-11019 ForwardHealth Prior Authorization / Physician Otological Report (PA/POR) Word None English
HCF-11019A F-11019A ForwardHealth Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions (PDF, 49 KB) PDF None English
HCF-11020 F-11020 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) (PDF, 122 KB) PDF None English
HCF-11020 F-11020 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Word None English
HCF-11020A F-11020A ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Completion Instructions (PDF, 54 KB) PDF None English
HCF-11021 F-11021 ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services (PDF, 154 KB) PDF None English
HCF-11021 F-11021 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) Word None English
HCF-11021A F-11021A ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services Completion Instructions (PDF, 39 KB) PDF None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data (PDF, 54 KB) PDF None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data Word None English
HCF-11023 F-11023 Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Excel None English
HCF-11023A F-11023A Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Completion Instructions (PDF, 20 KB) PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary (PDF, 37 KB) Encounters Submitted to Medicaid HMOs (PDF, 37 KB) PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs Word None English
HCF-11025A F-11025A Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary (PDF, 20 KB) Encounters Submitted to Medicaid HMOs Instructions (PDF, 20 KB) PDF None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs (PDF, 30 KB) PDF None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Word None English
HCF-11026A F-11026A Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Completion Instructions (PDF, 15 KB) PDF None English
HCF-11027 F-11027 Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Excel None English
HCF-11027A F-11027A Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Instructions (PDF, 19 KB) PDF None English
HCF-11029 F-11029 ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) (PDF, 52 KB) PDF None English
HCF-11029 F-11029 ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) Word None English
HCF-11029A F-11029A ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) Completion Instructions (PDF, 43 KB) PDF None English
HCF-11030 F-11030 ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) (PDF, 67 KB) PDF None English
HCF-11030 F-11030 ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Word None English
HCF-11030A F-11030A ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Completion Instructions (PDF, 40 KB) PDF None English
HCF-11031 F-11031 ForwardHealth Prior Authorization / Psychotherapy Attachment (PA/PSYA) (PDF, 47 KB) PDF None English
HCF-11031 F-11031 ForwardHealth Prior Authorization / Psychotherapy Attachment (PA/PSYA) Word None English
HCF-11031A F-11031A ForwardHealth Prior Authorization / Psychotherapy Attachment (PA / PSYA) Completion Instructions (PDF, 39 KB) PDF None English
HCF-11032 F-11032 ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) (PDF, 129 KB) PDF None English
HCF-11032 F-11032 ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) Word None English
HCF-11032A F-11032A ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) Instructions (PDF, 64 KB) PDF None English
HCF-11033 F-11033 ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) (PDF, 38 KB) PDF None English
HCF-11033 F-11033 ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Word None English
HCF-11033A F-11033A ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Completion Instructions (PDF, 49 KB) PDF None English
HCF-11034 F-11034 ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) (PDF, 73 KB) PDF None English
HCF-11034 F-11034 ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) Word None English
HCF-11034A F-11034A ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) Completion Instructions (PDF, 42 KB) PDF None English
HCF-11035 F-11035 ForwardHealth Prior Authorization Dental Request (PA / DRF) (PDF, 64 KB) PDF None English
HCF-11035 F-11035 ForwardHealth Prior Authorization Dental Request Form Word None English
HCF-11035A F-11035A ForwardHealth Prior Authorization Dental Request Form [PA / DRF] Completion Instructions (PDF, 64 KB) PDF None English
HCF-11036 F-11036 ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) (PDF, 104 KB) PDF None English
HCF-11036 F-11036 ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) Word None English
HCF-11036A F-11036A ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA/ITA) Completion Instructions (PDF, 56 KB) PDF None English
HCF-11037 F-11037 ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) (PDF, 81 KB) PDF None English
HCF-11037 F-11037 ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Word None English
HCF-11037A F-11037A ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Instructions (PDF, 60 KB) PDF None English
HCF-11038 F-11038 ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) (PDF, 80 KB) PDF None English
HCF-11038 F-11038 ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Word None English
HCF-11038A F-11038A ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Instructions (PDF, 47 KB) PDF None English
HCF-11039 F-11039 ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) (PDF, 76 KB) PDF None English
HCF-11039 F-11039 ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) Word None English
HCF-11039A F-11039A ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) Completion Instructions (PDF, 51 KB) PDF None English
HCF-11040 F-11040 ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) (PDF, 103 KB) PDF None English
HCF-11040 F-11040 ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Word None English
HCF-11040A F-11040A ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Completion Instructions (PDF, 100 KB) PDF None English
HCF-11041 F-11041 ForwardHealth Private Duty Nursing Prior Authorization Acknowledgment (PDF, 91 KB) PDF None English
HCF-11041 F-11041 ForwardHealth Private Duty Nursing Prior Authorization Acknowledgment Word None English
HCF-11042 F-11042 ForwardHealth Prior Authorization Amendment Request (PDF, 65 KB) PDF None English
HCF-11042 F-11042 ForwardHealth Prior Authorization Amendment Request Word None English
HCF-11042A F-11042A ForwardHealth Prior Authorization Amendment Request Completion Instructions (PDF, 27 KB) PDF None English
HCF-11044 F-11044 ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) (PDF, 68 KB) PDF None English
HCF-11044 F-11044 ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Word None English
HCF-11044A F-11044A ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Completion Instructions (PDF, 68 KB) PDF None English
HCF-11047 F-11047 Wisconsin Medicaid - Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 (PDF, 24 KB) PDF None English
HCF-11048 F-11048 Wisconsin Medicaid - Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission (PDF, 29 KB) PDF None English
HCF-11051 F-11051 ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) (PDF, 85 KB) PDF None English
HCF-11051 F-11051 ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) Word None English
HCF-11051A F-11051A ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) Completion Instructions (PDF, 39 KB) PDF None English
HCF-11052 F-11052 ForwardHealth STAT-PA Orthopedic Shoes Worksheet (PDF, 144 KB) PDF None English
HCF-11052 F-11052 ForwardHealth STAT-PA Orthopedic Shoes Worksheet Word None English
HCF-11052A F-11052A ForwardHealth STAT-PA Orthopedic Shoes Worksheet Completion Instructions (PDF, 98 KB) PDF None English
HCF-11054 F-11054 ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) (PDF, 626 KB) PDF None English
HCF-11054 F-11054 ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Word None English
HCF-11054A F-11054A ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Completion Instructions (PDF, 55 KB) PDF None English
HCF-11055 F-11055 ForwardHealth STAT-PA System Instructions (PDF, 28 KB) PDF None English
HCF-11062 F-11062 ForwardHealth Prior Authorization / Environmental Lead Inspection (PDF, 104 KB) PDF None English
HCF-11062 F-11062 ForwardHealth Prior Authorization / Environmental Lead Inspection Word None English
HCF-11062A F-11062A ForwardHealth Prior Authorization / Environmental Lead Inspection Instructions for Paper Prior Authorization or STAT-PA (PDF, 63 KB) PDF None English
HCF-11066 F-11066 ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) (PDF, 173 KB) PDF None English
HCF-11066 F-11066 ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) Word None English
HCF-11066A F-11066A ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) Completion Instructions (PDF, 51 KB) PDF None English
HCF-11067 F-11067 ForwardHealth Record of Actual Daily Oxygen Use (PDF, 127 KB) PDF None English
HCF-11067 F-11067 ForwardHealth Record of Actual Daily Oxygen Use Word None English
HCF-11067A F-11067A ForwardHealth Record of Actual Daily Oxygen Use Completion Instructions (PDF, 28 KB) PDF None English
HCF-11076 F-11076 ForwardHealth Prior Authorization Request (PA / RF) Completion Instructions for Residential Care Center Treatment Services (PDF, 36 KB) PDF None English
HCF-11076A F-11076A ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC (PDF, 105 KB) PDF None English
HCF-11076A F-11076A ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC Word None English
HCF-11076B F-11076B ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services Word None English
HCF-11076C F-11076C ForwardHealth Prior Authorization / Residential Care Center Treatment Attachment (PA / RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services (PDF, 34 KB) PDF None English
HCF-11079 F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Excel None English
HCF-11079A F-11079A Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Completion Instructions (PDF, 24 KB) PDF None English
HCF-11080 F-11080 Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Excel None English
HCF-11080A F-11080A Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Completion Instructions (PDF, 27 KB) PDF None English
HCF-11080CA F-11080CA Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Completion Instructions (PDF, 23 KB) PDF None English
HCF-11080CP F-11080CP Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Excel None English
HCF-11081 F-11081 Wisconsin Medicaid Rural Health Clinic Provider Staff Encounters Excel None English
HCF-11088 F-11088 ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) (PDF, 41 KB) PDF None English
HCF-11088 F-11088 ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Word None English
HCF-11088A F-11088A ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Completion Instructions (PDF, 37 KB) PDF None English
HCF-11090 F-11090 ForwardHealth Mental Health Day Treatment Functional Assessment (PDF, 169 KB) PDF None English
HCF-11090 F-11090 ForwardHealth Mental Health Day Treatment Functional Assessment Word None English
HCF-11090A F-11090A ForwardHealth Mental Health Day Treatment Functional Assessment Completion Instructions (PDF, 47 KB) PDF None English
HCF-11092 F-11092 ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs (PDF, 65 KB) PDF None English
HCF-11092 F-11092 ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Word None English
HCF-11092A F-11092A ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Completion Instructions (PDF, 64 KB) PDF None English
HCF-11096 F-11096 ForwardHealth Prior Authorization / Care Plan Attachment (for dates of service on or after May 1, 2010) (PDF, 69 KB) PDF None English
HCF-11096 F-11096 ForwardHealth Prior Authorization / Care Plan Attachment (for dates of service on or after May 1, 2010) Word None English
HCF-11096A F-11096A ForwardHealth Prior Authorization / Care Plan Attachment Completion Instructions (for dates of service on or after May 1, 2010) (PDF, 68 KB) PDF None English
HCF-11103 F-11103 ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (PDF, 154 KB) PDF None English
HCF-11103 F-11103 ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Word None English
HCF-11103A F-11103A ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Completion Instructions (PDF, 36 KB) PDF None English
HCF-11129A F-11129A Wisconsin Medicaid Federally Qualified Health Center Cost Report Completion Instructions (PDF, 53 KB) PDF None English
HCF-11129B-H F-11129B-H Wisconsin Medicaid Federally Qualified Health Center Cost Report Forms Excel None English
HCF-11130 F-11130 Wisconsin Medicaid Federally Qualified Health Center Interim Report Excel None English
HCF-11130A F-11130A Wisconsin Medicaid Federally Qualified Health Center Interim Report Completion Instructions (PDF, 27 KB) PDF None English
HCF-11133 F-11133 ForwardHealth Personal Care Screening Tool (PCST) (PDF, 91 KB) PDF None English
HCF-11133 F-11133 ForwardHealth Personal Care Screening Tool (PCST) Word None English
HCF-11133A F-11133A ForwardHealth Personal Care Screening Tool (PCST) Completion Instructions (PDF, 163 KB) PDF None English
HCF-11134 F-11134 ForwardHealth Personal Care Prior Authorization Provider Acknowledgement (PDF, 46 KB) PDF None English
HCF-11134 F-11134 ForwardHealth Personal Care Prior Authorization Provider Acknowledgement Word None English
HCF-11136 F-11136 ForwardHealth Personal Care Addendum (PDF, 215 KB) PDF None English
HCF-11136 F-11136 ForwardHealth Personal Care Addendum Word None English
HCF-11136A F-11136A ForwardHealth Personal Care Addendum Completion Instructions (PDF, 47 KB) PDF None English
HCF-11237 F-11237 Wisconsin Medicaid Specialized Medical Vehicle Provider Affidavit (PDF, 41 KB) PDF None English
HCF-11237 F-11237 Wisconsin Medicaid Specialized Medical Vehicle Provider Affidavit Word None English
HCF-11240 F-11240 Wisconsin Medicaid Case Management Provider Information (PDF, 63 KB) PDF None English
HCF-11240 F-11240 Wisconsin Medicaid Case Management Provider Information Word None English
HCF-11245 F-11245 Wisconsin Medicaid Family Planning Clinics or Agencies (PDF, 52 KB) PDF None English
HCF-11245 F-11245 Wisconsin Medicaid Family Planning Clinics or Agencies Word None English
HCF-11247 F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) (PDF, 41 KB) PDF None English
HCF-11247 F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) Word None English
HCF-11248 F-11248 Wisconsin Medicaid - Services that cannot be billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2) (PDF, 52 KB) PDF None English
HCF-11248 F-11248 Wisconsin Medicaid - Services that cannot be billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2) Word None English
HCF-11252 F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum(PDF, 46 KB) PDF None English
HCF-11252 F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum Word None English
HCF-11257 F-11257 Wisconsin Medicaid - Private Duty Nurse (PDN) Providers Addendum For Nurses in Independent Practice (PDF, 22 KB) PDF None English
HCF-11257 F-11257 Wisconsin Medicaid - Private Duty Nurse (PDN) Providers Addendum For Nurses in Independent Practice Word None English
HCF-11258 F-11258 Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Life-Support Adult (Age 17 and Over) (PDF, 534 KB) PDF None English
HCF-11258 F-11258 Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Life-Support Adult (Age 17 and Over) Word None English
HCF-11259 F-11259 Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Lifge-Support Pediatric (Ages 0-16) (PDF, 531 KB) PDF None English
HCF-11259 F-11259 Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Lifge-Support Pediatric (Ages 0-16) Word None English
HCF-11260 F-11260 Wisconsin Medicaid Degree Addendum (PDF, 24 KB) PDF None English
HCF-11260 F-11260 Wisconsin Medicaid Degree Addendum Word None English
HCF-11268 F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification (PDF, 100 KB) PDF None English
HCF-11271 F-11271 Wisconsin Medicaid Personal Care Provider Addendum (PDF, 22 KB) PDF None English
HCF-11271 F-11271 Wisconsin Medicaid Personal Care Provider Addendum Word None English
HCF-11278 F-11278 Wisconsin Medicaid PreNatal Care Coordination Outreach and Management Plan (PDF, 55 KB) PDF None English
HCF-11278 F-11278 Wisconsin Medicaid PreNatal Care Coordination Outreach and Management Plan Word None English
HCF-11279 F-11279 Wisconsin Medicaid Memorandum of Understanding (Sample Format) between HMO and Prenatal Care Coordination Agency (PDF, 27 KB) PDF None English
HCF-11279 F-11279 Wisconsin Medicaid Memorandum of Understanding (Sample Format) between HMO and Prenatal Care Coordination Agency Word None English
HCF-11285 F-11285 Wisconsin Medicaid HealthCheck Screener Affirmation (PDF, 32 KB) PDF None English
HCF-11285 F-11285 Wisconsin Medicaid HealthCheck Screener Affirmation Word None English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan (PDF, 29 KB) PDF None English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan Word None English
HCF-11309 F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification (PDF, 92 KB) PDF None English
HCF-11317 F-11317 ForwardHealth Certification Criteria For Providers Express Enrollment of Pregnant Women in BadgerCare Plus (PDF, 42 KB) PDF None English
HCF-11318 F-11318 ForwardHealth Certification Criteria For Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus (PDF, 42 KB) PDF None English
HCF-13509 F-13509 Wisconsin Well Woman Program Provider Certification (PDF, 385 KB) PDF None English