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-01160 | Acknowledgement of Receipt of Hysterectomy Information | DMS | None |
| F-11033 | Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) | DMS | None |
| F-44771D | Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-01199 | Optional School-Based Services Activity Medication Administration | DMS | None |
| F-60945 | Adult Family Home Initial Licensure Application | DQA | None |
| F-01182 | Declaration of Supervision for Nonbilling Providers | DMS | None |
| F-60947 | Adult Day Care Initial Certification Checklist | DQA | None |
| F-13066 | Claim Refund | DMS | None |
| F-11029 | Prior Authorization / Chiropractic Attachment (PA/CA) | DMS | None |
| F-45015 | Application for Radioactive Material License for Broad Scope | DPH | None |
| F-62380 | Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application | DQA | None |
| F-05034 | Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. | DPH | Other |
| F-11036 | Prior Authorization / In-Home Treatment Attachment (PA / ITA) | DMS | None |
| F-11011 | Prior Authorization / Birth to 3 Attachment (PA/B3) | DMS | None |
| F-11103 | Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan | DMS | None |
| F-01149 | Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements | DMS | None |
| F-11044 | Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) | DMS | None |
| F-62381 | Residential Care Apartment Complex (RCAC) Regulations Compliance Statement | DQA | None |
| F-01066A | HealthCheck Child's Food Record / 1 to 12 Years of Age | DMS | None |
| F-11037 | Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) | DMS | None |
| F-11014 | Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services | DMS | None |
| F-11066 | Prior Authorization / Oxygen Attachment (PA/OA) | DMS | None |
| F-11031 | Prior Authorization / Psychotherapy Attachment (PA/PSYA) | DMS | None |
| F-45017 | Application for Radioactive Material License Authorizing the Use of Sealed Sources | DPH | None |
| F-13393 | Trading Partner 835 Designation | DMS | None |
| F-01186 | Wisconsin Chronic Renal Disease Program Application | DMS | None |
| F-45011 | Certificate - In Vitro Testing with Radioactive Material Under General License | DPH | None |
| F-62418 | Adult Day Care Initial Certification Application | DQA | None |
| F-01066B | HealthCheck Adolescent's Food Record (13 to 20 Years of Age) | DMS | None |
| F-01168 | Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases | DMS | None |
| F-11038 | Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) | DMS | None |
| F-00622 | Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable | DMS | None |
| F-00212 | Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery | DMS | None |
| F-00020 | Drug Addition Review Request | DMS | None |
| F-00885 | Specialized Medical Vehicle Insurance Documentation Checklist | DMS | None |
| F-00280 | Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other | DMS | None |
| F-01009A | Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under | DMS | None |
| F-11019 | Prior Authorization / Physician Otological Report (PA/POR) | DMS | None |
| F-00239 | Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips | DMS | None |
| F-11034 | Prior Authorization / "J" Code Attachment (PA/JCA) | DMS | None |
| F-00281 | Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents | DMS | None |
| F-11051 | Prior Authorization / Vision Services Attachment (PA/VA) | DMS | None |
| F-11041 | Private Duty Nursing Prior Authorization Acknowledgment | DMS | None |
| F-11136 | Personal Care Addendum | DMS | None |
| F-01009B | Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older | DMS | None |
| F-00142 | Prior Authorization / Drug Attachment for Synagis® | DMS | None |
| F-01018 | Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers | DMS | None |
| F-11021 | Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) | DMS | None |
| F-00916 | Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request | DMS | None |
| F-00433 | Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets | DMS | None |
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Last Revised: March 26, 2019
