Official DHS Forms Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions. When you are searching for a document, enter the number or a portion of the title in the search box below. To narrow your search results even more, place quotation marks (" ") around search terms.

If you are looking for an informative document, visit our Informative Documents and Publications Library. If you need a file in another file format or can't find what you are looking for here, reach out to the Digital Communications Team at dhsfmorder@dhs.wisconsin.gov. You can typically expect a response within 1-2 business days.

Assigned Number Title Sort descending Division Language Release Date File Type Available to Order
F-03175 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Interferons DMS English 07/2023 Word
F-03175A Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents, Interferons Instructions DMS English 07/2023 PDF
F-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS English 11/2019 PDF
F-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS English 11/2019 Word
F-02537A Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting, Instructions DMS English 11/2019 PDF
F-02573 Prior Authorization Drug Attachment for Wakix DMS English 10/2024 PDF
F-02573 Prior Authorization Drug Attachment for Wakix DMS English 10/2024 Word
F-02573A Prior Authorization Drug Attachment for Wakix, Instructions DMS English 10/2024 PDF
F-01430 Prior Authorization Drug Attachment for Xyrem and Xywav DMS English 12/2021 PDF
F-01430 Prior Authorization Drug Attachment for Xyrem and Xywav DMS English 12/2021 Word
F-01430A Prior Authorization Drug Attachment for Xyrem and Xywav, Instructions DMS English 12/2021 PDF
F-01176 Prior Authorization Fax Cover Sheet DMS English 09/2022 Word
F-01176 Prior Authorization Fax Cover Sheet DMS English 09/2022 PDF
F-02815 Prior Authorization for Hospital Prolonged Stay DMS English 04/2022 Word
F-02815 Prior Authorization for Hospital Prolonged Stay DMS English 04/2022 PDF
F-02815 Prior Authorization for Hospital Prolonged Stay Fax Cover Sheet DMS English 01/2022 Word
F-02815A Prior Authorization for Hospital Prolonged Stay Fax Cover Sheet DMS English 01/2022 PDF
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS English 07/2012 Word
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS English 07/2012 PDF
F-11021 Prior Authorization Request / Hearing Instrument and Audiological Services DMS English 07/2012 PDF
F-11021A Prior Authorization Request / Hearing Instrument and Audiological Services (PA/HIAS2) Completion Instructions DMS English 11/2008 PDF
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS English 05/2013 PDF
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS English 05/2013 Word
F-11020A Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Completion Instructions DMS English 02/2016 PDF
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS English 07/2012 Word
F-11018 Prior Authorization Request Form (PA/RF) DMS English 05/2013 Word
F-11018 Prior Authorization Request Form (PA/RF) DMS English 05/2013 PDF
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS English 02/2019 Word
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS English 02/2019 PDF
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS English 04/2017 PDF
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS English 04/2017 Word
F-11083A Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA): Completion Instructions DMS English 04/2017 PDF
F-11049 Prior Authorization/Drug Attachment (PA/DGA) DMS English 01/2024 PDF
F-11049 Prior Authorization/Drug Attachment (PA/DGA) DMS English 01/2024 Word
F-11049A Prior Authorization/Drug Attachment (PA/DGA), Instructions DMS English 01/2024 PDF
F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA) DMS English 06/2023 PDF
F-11054 Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA) DMS English 06/2023 Word
F-11054A Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA), Completion Instructions DMS English 06/2023 PDF
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS English 02/2010 PDF
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS English 02/2010 Word
F-00212A Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment Instructions DMS English 12/2019 PDF
F-03327 Prior Authorization/Pediatric Hospital Bed (PA/PHB) DMS English 11/2024 PDF
F-03327 Prior Authorization/Pediatric Hospital Bed (PA/PHB) DMS English 11/2024 Word
F-03327A Prior Authorization/Pediatric Hospital Bed (PA/PHB), Instructions DMS English 11/2024 PDF
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 PDF
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 Word
F-11034A Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) Instructions DMS English 07/2022 PDF
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 PDF
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 Word
F-11075A Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, Instructions DMS English 07/2023 PDF

Glossary

 
Last revised December 4, 2024