Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Number Title Other Location
F-00219 Self-Employment Income Report: Farm Business
F-00107 Self-Employment Income Report
F-16076 FoodShare Six-Month Report and Instructions
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S)
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065)
F-11008 Prior Authorization / Therapy Attachment (PA/TA)
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services
F-02106C Adult Day Care Center – New Provider Certification Application
F-11051 Prior Authorization / Vision Services Attachment (PA/VA)
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age)
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-11027 Rural Health Clinic Quarterly Cost Report
F-01003 Wisconsin Medicaid Certification of Public Expenditures
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds)
F-01068L General Pediatric Clinic - Teenager Visit
F-01160 Acknowledgement of Receipt of Hysterectomy Information
F-13072 Noncompound Drug Claim
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-02107A Family Adult Day Care Center – Established Provider Certification Application
F-11041 Private Duty Nursing Prior Authorization Acknowledgment
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification
F-11237 Specialized Medical Vehicle Providers Affidavit
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1)
F-01204 Notice of Action—IRIS Program
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services
F-02106 Adult Day Care Center – Applicant Compliance Statement
F-01068F General Pediatric Clinic - 12 Month Visit
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA)
F-01204E Letter - IRIS Program Notice of Action - Functional Eligibility
F-02108B Adult Family Home – Established Provider Licensure Application Checklist
F-11035 Prior Authorization Dental Request Form (PA/DRF)
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan
F-01176 Prior Authorization Fax Cover Sheet
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-01199 Optional School-Based Services Activity Medication Administration
F-02106D Adult Day Care Center – New Provider Certification Application Checklist
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-01067 HealthCheck Your Child's Speech and Hearing
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor
F-00020 Drug Addition Review Request
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA)
F-02074 Medicare Other Coverage Discrepancy Report
F-01008 Wisconsin Medicaid Notification of Hospice Benefit Election
F-00632 Birth to 3 Program System of Payments - Consent to Access Insurance and Authorization to Release Information
F-11081 Rural Health Clinic Provider Staff Encounters
F-01302 Weekly Driver's Vehicle Inspection Report
F-01068M Confidential Health Survey

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Last Revised: March 26, 2019