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-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-01002 HealthCheck Individual Health History DMS
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services DMS
F-01068K General Pediatric Clinic - Elementary School Visit DMS
F-01153 Breast Pump Order DMS
F-01165 Newborn Report DMS
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-02074 Medicare Other Coverage Discrepancy Report DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS
F-00023 Case Management Agency Self-Audit Checklist DMS
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook DCTS
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) DMS
F-01234 Explanation of Medical Benefits DMS
F-01068E General Pediatric Clinic - 9 Month Visit DMS
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-01012 Reimbursement Request for a PASRR Level I Screen DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-01618 Client Services Agreement for Medicare Counseling DPH
F-01338 Children's Long-Term Support Parental Fee Declaration - Model DMS
F-13073 Compound Drug Claim DMS
F-11042 Prior Authorization Amendment Request DMS
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS
F-01003 Wisconsin Medicaid Certification of Public Expenditures DMS
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable DMS
F-11076A Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for Initial Admission and Unplanned Readmission within 90 Days of Discharge from RCC DMS
F-01270 Comprehensive Community Services Non-Traditional Approval DMS
F-01068L General Pediatric Clinic - Teenager Visit DMS
F-11129A Federally Qualified Health Center Cost Report Completion Instructions DMS
F-01159 Commercial Other Coverage Discrepancy Report DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-20448 Request for Medicaid Administrative Funds – Staff Position DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification DMS
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-01197 Certification of Need for Specialized Medical Vehicle Transportation DMS
F-00316 Child Enrollment Status Regarding Birth to 3 Program DMS
F-01391A Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook DCTS
F-11055 STAT-PA System Instructions DMS
F-01068F General Pediatric Clinic - 12 Month Visit DMS
F-20009 Complaint Report DCTS
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-01013 Nurse Aide Training and Competency Test Reimbursement Request DMS


Last Revised: March 26, 2019