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-10096 Community Spouse Asset Share
F-11132 Provider Agreement and Acknowledgement of Terms of Participation
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA)
F-10115 BadgerCare Plus / Medicaid Health Insurance Information
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant
F-11285 HealthCheck Screener Affirmation
F-11018 Prior Authorization Request Form (PA/RF)
F-11067 Record of Actual Daily Oxygen Use
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA)
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA)
F-10108 Medicaid Manual Notice for Cost of Care Contribution
F-11248 Services that cannot be Billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2)
F-11049 Prior Authorization / Drug Attachment (PA/DGA)
F-11318 Enrollment Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs
F-10097 Medicaid Income Allocation Notice
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA)
F-11289 HealthCheck County Outreach Case Management Plan for County
F-11019 Prior Authorization / Physician Otological Report (PA/POR)
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents
F-10175 Statement of Identity for Persons in Institutional Care Facilities
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA)
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update
F-10137 Medicaid Change Report
F-11252 Private Duty Nursing for Members for Ventilator-DependentLife-Support Addendum
F-11051 Prior Authorization / Vision Services Attachment (PA/VA)
F-11081 Rural Health Clinic Provider Staff Encounters
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information
F-11027 Rural Health Clinic Quarterly Cost Report
F-10098 Medicaid Member Asset Allocation Notice
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services
F-11041 Private Duty Nursing Prior Authorization Acknowledgment
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding
F-40096 WIC Program Repayment Agreement
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1)
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis
F-11076 Prior Authorization Request (PA/RF) Completion Instructions for Residential Care Center Treatment Services
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version
F-11035 Prior Authorization Dental Request Form (PA/DRF)
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application
F-11260 Degree Addendum
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA)
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA)
F-10154 Statement of Identity for Children Under 18 Years of Age
F-12023 Birth to Three Program Exemption Request Information and Instructions


Last Revised: July 28, 2017