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-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request
F-13066 Claim Refund
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions
F-13148 HIPAA Privacy Access Request
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization
F-13072 Noncompound Drug Claim
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions
F-13149 HIPAA Privacy Accounting Request
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request
F-13073 Compound Drug Claim
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions
F-13150 HIPAA Privacy Alternate Communication Request
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request
F-01284 Family Care, Family Care Partnership, and PACE Financial Reporting
F-13393 Trading Partner 835 Designation
F-13074 Pharmacy Special Handling Request
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request
F-13151 HIPAA Privacy Amendment Request
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request
F-13145 HIPAA Privacy Authorization for Use or Disclosure
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-10115 BadgerCare Plus / Medicaid Health Insurance Information
F-11018 Prior Authorization Request Form (PA/RF)
F-11067 Record of Actual Daily Oxygen Use
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA)
F-10108 Medicaid Manual Notice for Cost of Care Contribution
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs
F-10097 Medicaid Income Allocation Notice
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA)
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification
F-11019 Prior Authorization / Physician Otological Report (PA/POR)
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request
F-10175 Statement of Identity for Persons in Institutional Care Facilities
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA)
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan

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Last Revised: May 22, 2018