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-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-60945 Adult Family Home Initial Licensure Application DQA
F-01182 Declaration of Supervision for Nonbilling Providers DMS
F-60947 Adult Day Care Initial Certification Checklist DQA
F-13066 Claim Refund DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application DQA
F-05034 Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. DPH
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-62381 Residential Care Apartment Complex (RCAC) Regulations Compliance Statement DQA
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources DPH
F-13393 Trading Partner 835 Designation DMS
F-01186 Wisconsin Chronic Renal Disease Program Application DMS
F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License DPH
F-62418 Adult Day Care Initial Certification Application DQA
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-00622 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable DMS
F-00212 Prior Authorization / Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery DMS
F-00020 Drug Addition Review Request DMS
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-00280 Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other DMS
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-11136 Personal Care Addendum DMS
F-01009B Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older DMS
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-01018 Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers DMS
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request DMS
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS

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Last Revised: March 26, 2019