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-11018 Prior Authorization Request Form (PA/RF) DMS
F-01176 Prior Authorization Fax Cover Sheet DMS
F-00983 Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) DPH
F-00971 Request to Remove Yellow Fever Vaccine Vaccination Center DPH
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-01411 Education - Medication Summary - Part B DPH
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-01413 Post-Assessment Questionnaire DPH
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) DMS
F-11042 Prior Authorization Amendment Request DMS
F-01414 How Did We Do? DPH
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-43026 Wisconsin Donor Registry User Access Request DPH
F-13074 Pharmacy Special Handling Request DMS
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-01197 Certification of Need for Specialized Medical Vehicle Transportation DMS
F-01410 Education - Medication Summary - Part A DPH
F-44151 Acute and Communicable Disease Case Report DPH
F-02544 Nursing Home Immediate Jeopardy (IJ) Removal Plan DQA
F-01999 Foster Grandparent Program: State Match Funding Application DPH
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH
F-00047 Designated Asbestos Coordinator DPH
F-01999B Senior Companion Program: State Match Funding Application DPH
F-00539 County Waiver Agency Support and Service Coordination (SSC) Rates DMS
F-00905 Tuberculosis Infection (LTBI) Initial Request for Medication DPH
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH
F-00614 Physician, Physician Assistant, and Registered Nurse Equivalency Application DPH
F-02069 DHS Quarterly Report on Consumers Enrolled in CCS DCTS
F-02000 ADRC/Tribal ADRS/Aging System User: Access/Delete/Change DPH
F-00576 Tribal Aging and Disability Resource Specialist (TADRS) Application DPH
F-00053 Notice of Intent to Submit an Application (ADRC) DPH
F-01398 WISEWOMAN Client Home Blood Pressure Monitoring Agreement DPH
F-44444 WIC Vendor Supply Order DPH
F-01225 WISEWOMAN Healthy Behavior Encounter DPH
F-00576A Tribal Aging and Disability Resource Specialist (TADRS) Annual Budget DPH
F-20818 Certification for SSI-E Exceptional Expense Supplement DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-00567 Emergency Medical Services Complaint DPH
F-11260 Degree Addendum OIG
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH
F-00893 Affidavit of No Social Security Number - EMS Professional License DPH
F-00569 Request for Waiver of Administrative Rule for Licensure DPH
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS
F-11271 Personal Care Provider Addendum DMS
F-82009TC Confidential Information Release Authorization for Transportation Complaint Research DMS
F-20812 SSI-E Natural Residential Setting Application Checklist DMS
F-82018C Work Time Absence Record DES
F-11240 Case Management Provider Information OIG
F-20817 Assessment Worksheet for Natural Residential Setting DMS


Last Revised: March 26, 2019