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-10183 Information Change Report DMS
F-02590 Ongoing Review of Nonresidential Group Supported Employment Site Surveys DMS
F-00401 Prior Authorization/Preferred Drug List (PA/PDL) for Expedited Emergency Supply Request DMS
F-00221 Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions DPH
F-01344 Strategies for Success with People Who Have Dementia-Behavior Analysis Worksheet-Model DPH
F-021343G AFCSP Fiscal Report DPH
F-02587 Children's Long-Term Support (CLTS) Waiver Program Deciding Together Implementation Planning Tool DMS
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa DMS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents DMS
F-02573 Prior Authorization Drug Attachment for Wakix DMS
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine DMS
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents DMS
F-02371 Prior Authorization Drug Attachment for Migraine Agents, Calcitonin Gene-Related Peptide (CGRP) Antagonists DMS
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-40036 Agreement Between the State of Wisconsin and the Wisconsin Women, Infant, and Children (WIC) Vendor DPH
F-00366 Wisconsin Adult Long-Term Care Functional Screen DMS
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions DPH
F-02484 Pace Program Member Requested Disenrollment or Transfer Instructions DPH
F-02403 Family Care, Partnership, PACE, and IRIS Program Requested Disenrollment DPH
F-00534 Partnership Member Requested Disenrollment or Transfer and Instructions DPH
F-10076 SeniorCare Application DMS
F-01423 HIV Drug Assistance and Insurance Assistance Program, Insurance Enrollment Report DPH
F-02588 Financial Exploitation Tracking for Counties DPH
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-02250 Quarterly Program Integrity Report OIG
F-00036 Power of Attorney for Finance and Property DPH
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-01629 Prior Authorization / Behavioral Treatment Attachment (PA/BTA) DMS
F-02574 Wisconsin Assistive Technology Advisory Council Application DPH
F-00212 Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH
F-01421 WISEWOMAN Monthly Reporting for Direct Services DPH
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-01781 Immunization Program Functional Exercise 2018-2020 (BP1 Supplemental) DPH
F-02562 Disability Benefit Specialist Program Client Services Agreement DPH
F-02583 Options Counseling Record Review Tool DPH
F-40093 Annual ROSIE User Security and Confidentiality Agreement DPH
F-80857 Special CARS Run request DES
F-20891 Intoxicated Driver Program Supplemental Funding Request DCTS
F-16030 FoodShare Wisconsin Under / Overissuance Worksheet and Overpayment Calculator DMS
F-11133 Personal Care Screening Tool (PCST) DMS
F-16004 Add or Remove an Authorized Buyer or Alternate Payee for FoodShare Benefits DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-20483 Wisconsin Incident Tracking System (WITS) Web Access Request DPH
F-16033 FoodShare Worksheet DMS

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Last Revised: March 26, 2019