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-02505 Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions
F-00079 Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil
F-01952 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Giant Cell Arteritis, Neonatal Onset Multisystem Inflammatory Disease (NOMID), and Non-Radiographic Axial Sponyloarthritis (nr-axSpA)
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine
F-02371 Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists
F-00367B Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months
F-44012 Lead Abatement Notification
F-00520 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Detoxification Service Initial Certification Application - DHS 75.06
F-00401 ForwardHealth Expedited Emergency Supply Request
F-00628 Consortium Response to the State IM Second Party Review Finding
F-00740 Quality Improvement Event Analysis Summary and Suggested Event Analysis Process
F-00685 Statement of Tribal Affiliation
F-00154 Wisconsin Consultative Examination Inquiry
F-01204F IRIS Program Notice of Action Letter – Denied Provider Change
F-22191 Pre-Admission Screen and Resident Review (PASARR) Level 1 Screen
F-00100 State Vital Records Birth Certificate Request Letter
F-02483 PACE Program Enrollment
F-00101 Authorization to Request Birth Records
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application
F-62594 Notice of Substantial Change Feeding Assistant Training Program
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions
F-00076 Variance Request – Waitlist
F-00533 Partnership Programs - Enrollment
F-01593A Civil Money Penalty (CMP) Funded Project Report
F-00098 Summary of Information Letter
F-11067 Record of Actual Daily Oxygen Use
F-01270 Comprehensive Community Services Non-Traditional Approval
F-01068L General Pediatric Clinic - Teenager Visit
F-01673 Effective 01/01/2016: Prior Authorization / Preferred Drug List (PA/PDL) for Belsomra®
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-11018 Prior Authorization Request Form (PA/RF)
F-01003 Wisconsin Medicaid Certification of Public Expenditures
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA)
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA)
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex
F-01068F General Pediatric Clinic - 12 Month Visit
F-01197 Certification of Need for Specialized Medical Vehicle Transportation
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets
F-01159 Commercial Other Coverage Discrepancy Report
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs
F-01013 Nurse Aide Training and Competency Test Reimbursement Request
F-01067 HealthCheck Your Child's Speech and Hearing
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services
F-13066 Claim Refund


Last Revised: March 26, 2019