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 Numbersort descending Title Other Location Language
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents English
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips English
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) English
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use English
F-00258 Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services (PDF, 185 KB) English
F-00260 Community Recovery Services - Service Plan Packet Quality Review Results English
F-00261 Personal Care Agency Personnel Record Review English
F-00262 Personal Care Agency Application Materials Checklist English
F-00262A Personal Care Agency Application Regulatory Guidance Checklist English
F-00263 Personal Care Agency Record Review English
F-00264 Personal Care Agency Surveyor Guide English
F-00272 WisTech Assistive Technology Advisory Council Member Application English
F-00273 Behavioral Health Services Initial Certification Application - DHS 94 English
F-00276 Behavioral Health Services Renewal Certification Application - DHS 94 and 92 English
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other English
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents English
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections English
F-00295 Medical and Remedial Expenses Checklist - Update English
F-00301 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application English
F-00302 Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 English
F-00303 2009 ACT 198 Request for Approval to Issue Identification Cards (Access to Toilet Facilities in Retail Establishments) (PDF, 36 KB) English
F-00309 Medicaid Provider Report English
F-00311 Nursing Home MDS 3.0 Section Q Referral English
F-00312 Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Community Recovery Services Provider Entities English
F-00312A Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation for Individual or Non-specified Community Recovery Services Providers English
F-00315 Written Prior Notice - Birth to 3 English
F-00315A Written Prior Notice - No Evaluation Recommended English
F-00315B Transition Written Prior Notice English
F-00315C Prior Notice and Consent for Evaluation - Birth to 3 English
F-00315D Written Prior Notice - Additional Assessments Recommended English
F-00316 Child Enrollment Status Regarding Birth to 3 Program English
F-00321 OBVI Initial Interview Assessment English
F-00330 Request for Replacement FoodShare Benefits English
F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) English
F-00334 Money Follows the Person (MFP) - Participant Reporting English
F-00335 Voluntary Agreement for Crisis Stabilization Services English
F-00336 Tickborne Rickettsial Disease Case Report (PDF, 530 KB) English
F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey English
F-00340 Authorization and Release - Photograph, Video, and/or Audio Recording (PDF, 15 KB) English
F-00341 Community Recovery Services Terms of Reimbursement (PDF, 45 KB) English
F-00342 HealthCheck Other Services WIC Agency Provider Terms of Reimbursement (PDF, 41 KB) English
F-00343 Eligibility Management (Income Maintenance) Policy Notification Sign-Up English
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services English
F-00355 Healthiest Wisconsin 2020 Implementation Plan Endorsement English
F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application (PDF, 25 KB) English
F-00366 Wisconsin Adult Long-Term Care Functional Screen English
F-00367 Functional Eligibility Screen for Children's Long-Term Support Programs English
F-00367A Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: Birth - 6 Months (PDF, 19 KB) English
F-00367B Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 6 - 12 Months (PDF, 23 KB) English
F-00367C Age-Specific ADL / IADL Answer Choices for Children's Long-Term Support Programs Age: 12 to 18 Months (PDF, 24 KB) English

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Last Revised: July 28, 2017