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.
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| 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 | None |
| F-01430 | Prior Authorization Drug Attachment for Xyrem | None |
| F-00075 | IRIS (Include, Respect, I Self-Direct) Authorization | None |
| F-44614A | AIDS/HIV Drug Assistance Program and Insurance Assistance Program Application / Recertification | None |
| F-02404 | Family Care, Partnership, PACE, or IRIS Change Routing Instructions | None |
| 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 | None |
| F-44614I | AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions | None |
| 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) | None |
| F-11304 | Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis | None |
| F-11306 | Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis | None |
| F-00046 | Family Care Program - Enrollment | None |
| F-02433 | Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex | None |
| F-02436A | PrEP Questionnaire | None |
| F-02441 | Wisconsin Interpreting and Transliterating Assessment (WITA) Permanent Status Request | None |
| F-11010 | Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format | None |
| F-00079 | Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil | None |
| F-60289 | Waiver or Variance Request - Community Mental Health and Substance Abuse Programs | None |
| F-01204B | Letter - IRIS Program Notice of Action - Limit | None |
| F-01204F | IRIS Program Notice of Action Letter – Denied Provider Change | None |
| F-01442 | IRIS Disenrollment Letter - Death | None |
| F-01894 | Vendor Overpayment Findings Letter | None |
| F-01454 | IRIS Program Withdrawal Letter – No Progress | None |
| F-01556 | Medicaid Cost Share Letter - Initial | None |
| F-01442K | IRIS Program Disenrollment Letter - Policy Noncompliance | None |
| F-01319C | IRIS Program – Denial of Enrollment Letter | None |
| F-01442H | IRIS Program Disenrollment Letter – Voluntary | None |
| F-01942B | LTC FS - Request Letter | None |
| F-02400A | Client Transfer: Assisted Living Facility Capability | None |
| F-01468A | IRIS Program Start Date Letter – Transferring Participant | None |
| F-01204C | Letter - IRIS Program Notice of Action - Reduction | None |
| F-01563 | IRIS Consultant Agency (ICA) Provider Change Letter | None |
| F-01442A | IRIS Program Disenrollment Letter – Financial Eligibility | None |
| F-01556BB | IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter | None |
| F-01454A | IRIS Program Withdrawal Letter – Financial or Functional Eligibility | None |
| F-01556A | IRIS Program First Delinquent Medicaid Cost Share Payment Letter | None |
| F01454G | IRIS Program Withdrawal Letter - Cancelled | None |
| F-01442D | IRIS Program Disenrollment Letter – Incomplete Functional Screen | None |
| F-01942C | LTC FS - Release of Information Authorization | None |
| F-01556E | IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer | None |
| F-02400B | Client Transfer: Labels | None |
| F-01352A | IRIS Participant-Hired Worker Background Check Appeal Process Letter | None |
| F-01204D | Letter - IRIS Program Notice of Action - Termination | None |
| F-01442B | IRIS Program Disenrollment Letter – Functional Eligibility | None |
| F-01454B | IRIS Program Withdrawal Letter – Health and Safety | None |
| F-01556B | IRIS Program Second Delinquent Medicaid Cost Share Payment Letter | None |
| F-01293B | Fiscal Employer Agent (FEA) Change Denial Letter | None |
| F-01942D | LTC FS - Change in Condition - Release of Information Authorization | None |
| F-01352B | IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter | None |
| F-01942 | Long-Term Care Functional Screen (LTC-FS) - Annual Deadline | None |
| F-01204E | Letter - IRIS Program Notice of Action - Functional Eligibility | None |
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Last Revised: May 22, 2018
