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 Division Other Location
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement DQA
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-13066 Claim Refund DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-62418 Adult Day Care Initial Certification Application DQA
F-05034 Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. DPH
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-01018 Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers DMS
F-01389 ROSI Adult Satisfaction Survey DCTS
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request DMS
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS
F-11136 Personal Care Addendum DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable DMS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery DMS
F-00020 Drug Addition Review Request DMS
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other DMS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-01411 Education - Medication Summary - Part B DPH
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-01413 Post-Assessment Questionnaire DPH
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center DPH
F-43026 Wisconsin Donor Registry User Access Request DPH
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-13074 Pharmacy Special Handling Request DMS
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-01197 Certification of Need for Specialized Medical Vehicle Transportation DMS
F-01414 How Did We Do? DPH
F-11018 Prior Authorization Request Form (PA/RF) DMS
F-01176 Prior Authorization Fax Cover Sheet DMS
F-01410 Education - Medication Summary - Part A DPH
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) DMS
F-11042 Prior Authorization Amendment Request DMS
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) DPH
F-01228 WISEWOMAN Follow-up Assessment: LSP/HC Complete DPH
F-44151 Acute and Communicable Disease Case Report DPH
F-01999B Senior Companion Program: State Match Funding Application DPH

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Last Revised: March 26, 2019