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-29314 COP Declaration of Income and Assets, and State Residency
F-29315 Declaration of Income and Assets, and State Residency Instructions
F-01468 IRIS Program Start Date Letter – New Participant
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-01952 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Giant Cell Arteritis, and Neonatal Onset Multisystem Inflammatory Disease (NOMID)
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-00046 Family Care Program - Enrollment
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
F-01430 Prior Authorization Drug Attachment for Xyrem
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-02436A PrEP Questionnaire
F-02441 Wisconsin Interpreting and Transliterating Assessment (WITA) Permanent Status Request
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs
F-00079 Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil
F-01442E IRIS Program Disenrollment Letter – Ineligible Setting
F-01798 Retroactive Overtime To Be Calculated
F-01454D IRIS Program Withdrawal Letter – Non Eligible Setting
F-01556D IRIS Program Letter – Disenrollment
F-02424 National Fatality Review Case Reporting System: Access Request and Confidentiality Statement
F-01442J IRIS Program Disenrollment Letter - Mismanagement
F-01442F IRIS Program Disenrollment Letter – Missing Signature Page
F-01942A LTC FS - Diagnosis Verification Letter
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet
F-01454E IRIS Program Withdrawal Letter – Voluntary
F-01204A Letter - IRIS Program Notice of Action - Denial
F-01894 Vendor Overpayment Findings Letter
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-01442G IRIS Program Disenrollment Letter – Non-Spending
F-01619 OARS Welcome Letter
F-01942B LTC FS - Request Letter
F-02400A Client Transfer: Assisted Living Facility Capability
F-01204B Letter - IRIS Program Notice of Action - Limit
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-01442 IRIS Disenrollment Letter - Death
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-01454 IRIS Program Withdrawal Letter – No Progress
F-01556 Medicaid Cost Share Letter - Initial
F01454G IRIS Program Withdrawal Letter - Cancelled
F-01319C IRIS Program – Denial of Enrollment Letter
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-01942C LTC FS - Release of Information Authorization
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-02400B Client Transfer: Labels

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Last Revised: May 22, 2018