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-00239 | Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips | DMS | None |
| F-11020 | Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) | DMS | None |
| F-01002 | HealthCheck Individual Health History | DMS | None |
| F-11076 | Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services | DMS | None |
| F-01068K | General Pediatric Clinic - Elementary School Visit | DMS | None |
| F-01153 | Breast Pump Order | DMS | None |
| F-01165 | Newborn Report | DMS | None |
| F-20445 | Individual Service Plan – Children’s Long-Term Support Programs | DMS | None |
| F-00281 | Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents | DMS | None |
| F-11035 | Prior Authorization Dental Request Form (PA/DRF) | DMS | None |
| F-02074 | Medicare Other Coverage Discrepancy Report | DMS | None |
| F-11103 | Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan | DMS | None |
| F-00787 | Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services | DMS | None |
| F-00023 | Case Management Agency Self-Audit Checklist | DMS | None |
| F-11010 | Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format | DMS | None |
| F-01391 | Recovery Oriented System Indicator (ROSI) Adult Data Workbook | DCTS | None |
| F-11054 | Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) | DMS | None |
| F-01234 | Explanation of Medical Benefits | DMS | None |
| F-01068E | General Pediatric Clinic - 9 Month Visit | DMS | None |
| F-01134 | Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit | DMS | None |
| F-11029 | Prior Authorization / Chiropractic Attachment (PA/CA) | DMS | None |
| F-01012 | Reimbursement Request for a PASRR Level I Screen | DMS | None |
| F-11081 | Rural Health Clinic Provider Staff Encounters | DMS | None |
| F-01618 | Client Services Agreement for Medicare Counseling | DPH | None |
| F-01338 | Children's Long-Term Support Parental Fee Declaration - Model | DMS | None |
| F-13073 | Compound Drug Claim | DMS | None |
| F-11042 | Prior Authorization Amendment Request | DMS | None |
| F-01066B | HealthCheck Adolescent's Food Record (13 to 20 Years of Age) | DMS | None |
| F-11021 | Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) | DMS | None |
| F-01003 | Wisconsin Medicaid Certification of Public Expenditures | DMS | None |
| F-00622 | Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable | DMS | None |
| 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 | None |
| F-01270 | Comprehensive Community Services Non-Traditional Approval | DMS | None |
| F-01068L | General Pediatric Clinic - Teenager Visit | DMS | None |
| F-11129A | Federally Qualified Health Center Cost Report Completion Instructions | DMS | None |
| F-01159 | Commercial Other Coverage Discrepancy Report | DMS | None |
| F-01168 | Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases | DMS | None |
| F-20448 | Request for Medicaid Administrative Funds – Staff Position | DMS | None |
| F-11036 | Prior Authorization / In-Home Treatment Attachment (PA / ITA) | DMS | None |
| F-01050 | Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification | DMS | None |
| F-00805 | Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators | DMS | None |
| F-11011 | Prior Authorization / Birth to 3 Attachment (PA/B3) | DMS | None |
| F-01197 | Certification of Need for Specialized Medical Vehicle Transportation | DMS | None |
| F-00316 | Child Enrollment Status Regarding Birth to 3 Program | DMS | None |
| F-01391A | Mental Health Statistics Improvement Program (MHSIP) Youth Data Workbook | DCTS | None |
| F-11055 | STAT-PA System Instructions | DMS | None |
| F-01068F | General Pediatric Clinic - 12 Month Visit | DMS | None |
| F-20009 | Complaint Report | DCTS | None |
| F-11030 | Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) | DMS | None |
| F-01013 | Nurse Aide Training and Competency Test Reimbursement Request | DMS | None |
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Last Revised: March 26, 2019
