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 | Other Location |
|---|---|---|
| F-02441 | Wisconsin Interpreting and Transliterating Assessment (WITA) Permanent Status Request | None |
| F-02363 | Children's Long-Term Support Waiver Program Provider Agreement and Acknowledgement of Terms of Participation for Service Provider Agencies | None |
| 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 | None |
| 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 | None |
| F-22554 | Hearing Loss Certification Telecommunications Assistance Program (TAP) | None |
| F-25180 | Order of Discharge Upon Expiration of Commitment | None |
| F-44614I | AIDS/HIV Drug Assistance Program And Insurance Assistance Program Application/Recertification - Instructions | None |
| F-00236 | Request for a State Fair Hearing - MCO | None |
| F-01201A | IRIS Participant - Hired Worker Relationship Identification | None |
| F-00060 | Declaration to Physicians (Living Will) | Other |
| F-13073 | Compound Drug Claim | None |
| F-11304 | Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis | None |
| F-11306 | Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis | None |
| F-00556 | Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger | None |
| F-11077 | Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) | None |
| F-11049 | Prior Authorization / Drug Attachment (PA/DGA) | None |
| F-13072 | Noncompound Drug Claim | None |
| F-00315B | Transition Written Prior Notice | None |
| F-02051 | Wisconsin Donor Registry Enrollment | None |
| F-01261 | Fraud Statement - IRIS Program | None |
| F-44125 | Latent Tuberculosis Infection (LTBI) Follow-Up Report | None |
| F-01942 | Long-Term Care Functional Screen (LTC-FS) - Annual Deadline | None |
| F-29315 | Declaration of Income and Assets, and State Residency Instructions | None |
| 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) | None |
| F-01430 | Prior Authorization Drug Attachment for Xyrem | None |
| F-01950 | Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis | None |
| 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 | None |
| F-02433 | Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex | None |
| F-02404 | Family Care, Partnership, PACE, or IRIS Change Routing Instructions | None |
| F-11010 | Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format | None |
| F-60289 | Waiver or Variance Request - Community Mental Health and Substance Abuse Programs | None |
| F-00079 | Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil | None |
| F-01352A | IRIS Participant-Hired Worker Background Check Appeal Process Letter | None |
| F-01556C | IRIS Program Cost Share Repayment Plan Letter | None |
| F-01894 | Vendor Overpayment Findings Letter | None |
| F-01352B | IRIS Participant-Hired Worker Background Check Appeal Process - Ineligible Letter | None |
| F-01942A | LTC FS - Diagnosis Verification Letter | None |
| F-01556E | IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer | None |
| F-01556BB | IRIS Program Previous Delinquent Medicaid Cost Share Payment Letter | None |
| F-01942B | LTC FS - Request Letter | None |
| F-01293B | Fiscal Employer Agent (FEA) Change Denial Letter | None |
| F-01628 | OARS Enrollment Letter | None |
| F-01942C | LTC FS - Release of Information Authorization | None |
| F-01556 | Medicaid Cost Share Letter - Initial | None |
| F-01293C | Fiscal Employer Agent (FEA) Change Effective Date Letter | None |
| F-02400 | Client Transfer: Assisted Living Facility Client Face Sheet | None |
| F-01319C | IRIS Program – Denial of Enrollment Letter | None |
| F-01942D | LTC FS - Change in Condition - Release of Information Authorization | None |
| F-01556A | IRIS Program First Delinquent Medicaid Cost Share Payment Letter | None |
| F-02400A | Client Transfer: Assisted Living Facility Capability | None |
Pages
Last Revised: March 26, 2019
