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 Other Location
F-02441 Wisconsin Interpreting and Transliterating Assessment (WITA) Permanent Status Request
F-02363 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies
F-02364 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Sole Proprietor or Individual Waiver Service Providers
F-02365 Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Fiscal Agents Managing Self-Directed Waiver Supports
F-22554 Hearing Loss Certification Telecommunications Assistance Program (TAP)
F-25180 Order of Discharge Upon Expiration of Commitment
F-44614I AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions
F-00236 Request for a State Fair Hearing - MCO
F-01201A IRIS Participant - Hired Worker Relationship Identification
F-00060 Declaration to Physicians (Living Will)
F-13073 Compound Drug Claim
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-13072 Noncompound Drug Claim
F-00315B Transition Written Prior Notice
F-02051 Wisconsin Donor Registry Enrollment
F-01261 Fraud Statement - IRIS Program
F-44125 Latent Tuberculosis Infection (LTBI) Follow-Up Report
F-01942 Long-Term Care Functional Screen (LTC-FS) - Annual Deadline
F-29315 Declaration of Income and Assets, and State Residency Instructions
F-01952 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Uveitis, Giant Cell Arteritis, and Neonatal Onset Multisystem Inflammatory Disease (NOMID)
F-01430 Prior Authorization Drug Attachment for Xyrem
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis
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
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex
F-02404 Family Care, Partnership, PACE, or IRIS Change Routing Instructions
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format
F-60289 Waiver or Variance Request - Community Mental Health and Substance Abuse Programs
F-00079 Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil
F-01352A IRIS Participant-Hired Worker Background Check Appeal Process Letter
F-01556C IRIS Program Cost Share Repayment Plan Letter
F-01894 Vendor Overpayment Findings Letter
F-01352B IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter
F-01942A LTC FS - Diagnosis Verification Letter
F-01556E IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer
F-01556BB IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter
F-01942B LTC FS - Request Letter
F-01293B Fiscal Employer Agent (FEA) Change Denial Letter
F-01628 OARS Enrollment Letter
F-01942C LTC FS - Release of Information Authorization
F-01556 Medicaid Cost Share Letter - Initial
F-01293C Fiscal Employer Agent (FEA) Change Effective Date Letter
F-02400 Client Transfer: Assisted Living Facility Client Face Sheet
F-01319C IRIS Program – Denial of Enrollment Letter
F-01942D LTC FS - Change in Condition - Release of Information Authorization
F-01556A IRIS Program First Delinquent Medicaid Cost Share Payment Letter
F-02400A Client Transfer: Assisted Living Facility Capability

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Last Revised: March 26, 2019