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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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 | Division | Other Location |
|---|---|---|---|
| F-45010D | Training, Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) | DPH | None |
| F-45007 | Certificate of Disposition of Materials | DPH | None |
| F-45010E | Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy or Gamma Stereotactic Radiosurgery Units) | DPH | None |
| F-45008 | Application for Radioactive Material License for Medical Use | DPH | None |
| F-45010F | Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) | DPH | None |
| F-45010G | Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) | DPH | None |
| F-45010A | Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) | DPH | None |
| F-45010B | Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) | DPH | None |
| F-00740 | Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary | DQA | Other |
| F-62470 | Client/Patient/Resident Reportable Death Determination | DQA | None |
| F-45021 | Generally Licensed Device Inspection by Mail | DPH | None |
| F-01105 | Prenatal Care Coordination Pregnancy Questionnaire | DMS | None |
| F-22541 | Incident Report - Medicaid Waiver Programs | DMS | None |
| F-44771AA | Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning | DPH | None |
| F-01337 | Worksheet for Determination of Parental Payment Limit for CLTS | DMS | None |
| F-44771A | Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-01066 | HealthCheck Infant's Food Record (Birth to 12 Months of Age) | DMS | None |
| F-16004 | Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits | DMS | None |
| F-60795 | Community Based Residential Facility (CBRF) Fire Inspection | DQA | None |
| F-11011 | Prior Authorization / Birth to 3 Attachment (PA/B3) | DMS | None |
| F-62381 | Residential Care Apartment Complex (RCAC) Regulations Compliance Statement | DQA | None |
| F-11103 | Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan | DMS | None |
| F-11044 | Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) | DMS | None |
| F-01066A | HealthCheck Child's Food Record / 1 to 12 Years of Age | DMS | None |
| F-11037 | Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) | DMS | None |
| F-11066 | Prior Authorization / Oxygen Attachment (PA/OA) | DMS | None |
| F-11014 | Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services | DMS | None |
| F-62418 | Adult Day Care Initial Certification Application | DQA | None |
| F-13393 | Trading Partner 835 Designation | DMS | None |
| F-11031 | Prior Authorization / Psychotherapy Attachment (PA/PSYA) | DMS | None |
| F-01066B | HealthCheck Adolescent's Food Record (13 to 20 Years of Age) | DMS | None |
| F-44771D | Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-01186 | Wisconsin Chronic Renal Disease Program Application | DMS | None |
| F-11038 | Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) | DMS | None |
| F-01168 | Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases | DMS | None |
| F-11067 | Record of Actual Daily Oxygen Use | DMS | None |
| F-13470 | Claim Form Attachment Cover Page | DMS | None |
| F-11032 | Prior Authorization / Substance Abuse Attachment (PA/SAA) | DMS | None |
| F-01067 | HealthCheck Your Child's Speech and Hearing | DMS | None |
| F-11088 | Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) | DMS | None |
| F-60287 | Community-Based Residential Facility (CBRF) Initial Licensure Application | DQA | None |
| F-01160 | Acknowledgement of Receipt of Hysterectomy Information | DMS | None |
| F-01170 | Written Correspondence Inquiry | DMS | None |
| F-11075 | Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request | DMS | None |
| F-01198 | Optional School-Based Services Activity Log Nursing / Therapy Medical Services | DMS | None |
| F-11033 | Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) | DMS | None |
| F-45015 | Application for Radioactive Material License for Broad Scope | DPH | None |
| F-60945 | Adult Family Home Initial Licensure Application | DQA | None |
| F-40036 | Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor | DPH | None |
| F-01199 | Optional School-Based Services Activity Medication Administration | DMS | None |
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Last Revised: March 26, 2019
