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-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
F-01430 Prior Authorization Drug Attachment for Xyrem
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization
F-44614A AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification
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-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions
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-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
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-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-00079 Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs
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-01894 Vendor Overpayment Findings Letter
F-01454 IRIS Program Withdrawal Letter – No Progress
F-01556 Medicaid Cost Share Letter - Initial
F-01442K IRIS Program Disenrollment Letter - Policy Noncompliance
F-01319C IRIS Program – Denial of Enrollment Letter
F-01442H IRIS Program Disenrollment Letter – Voluntary
F-01942B LTC FS - Request Letter
F-02400A Client Transfer: Assisted Living Facility Capability
F-01468A IRIS Program Start Date Letter – Transferring Participant
F-01204C Letter - IRIS Program Notice of Action - Reduction
F-01563 IRIS Consultant Agency (ICA) Provider Change Letter
F-01442A IRIS Program Disenrollment Letter – Financial Eligibility
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-01454A IRIS Program Withdrawal Letter – Financial or Functional Eligibility
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter
F01454G IRIS Program Withdrawal Letter - Cancelled
F-01442D IRIS Program Disenrollment Letter – Incomplete Functional Screen
F-01942C LTC FS - Release of Information Authorization
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-02400B Client Transfer: Labels
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-01204D Letter - IRIS Program Notice of Action - Termination
F-01442B IRIS Program Disenrollment Letter – Functional Eligibility
F-01454B IRIS Program Withdrawal Letter – Health and Safety
F-01556B IRIS Program Second Delinquent Medicaid Cost Share Payment Letter
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter
F-01942D LTC FS - Change in Condition - Release of Information Authorization
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-01204E Letter - IRIS Program Notice of Action - Functional Eligibility

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Last Revised: May 22, 2018