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-45010B | Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) | DPH | None |
| F-45012 | Application for a Radioactive Material License for a Commercial Radiopharmacy | DPH | None |
| F-45021 | Generally Licensed Device Inspection by Mail | DPH | None |
| F-01105 | Prenatal Care Coordination Pregnancy Questionnaire | DMS | None |
| F-62470 | Client/Patient/Resident Reportable Death Determination | DQA | None |
| F-00740 | Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary | DQA | Other |
| F-01066 | HealthCheck Infant's Food Record (Birth to 12 Months of Age) | DMS | None |
| F-44771AA | Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning | DPH | None |
| F-44771A | Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-01186 | Wisconsin Chronic Renal Disease Program Application | DMS | None |
| F-11088 | Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) | DMS | None |
| F-01168 | Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases | DMS | None |
| F-11075 | Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request | DMS | None |
| F-60945 | Adult Family Home Initial Licensure Application | DQA | None |
| F-11033 | Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) | DMS | None |
| F-01170 | Written Correspondence Inquiry | DMS | None |
| F-01198 | Optional School-Based Services Activity Log Nursing / Therapy Medical Services | DMS | None |
| F-60947 | Adult Day Care Initial Certification Checklist | DQA | None |
| F-44771D | Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels | DPH | None |
| F-45015 | Application for Radioactive Material License for Broad Scope | DPH | None |
| F-01199 | Optional School-Based Services Activity Medication Administration | DMS | None |
| F-13066 | Claim Refund | DMS | None |
| F-62380 | Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application | DQA | None |
| F-11029 | Prior Authorization / Chiropractic Attachment (PA/CA) | DMS | None |
| F-01182 | Declaration of Supervision for Nonbilling Providers | DMS | None |
| F-05034 | Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. | DPH | Other |
| 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-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-11044 | Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) | DMS | None |
| F-45017 | Application for Radioactive Material License Authorizing the Use of Sealed Sources | DPH | None |
| F-62418 | Adult Day Care Initial Certification Application | DQA | None |
| F-11037 | Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) | DMS | None |
| F-01066B | HealthCheck Adolescent's Food Record (13 to 20 Years of Age) | DMS | None |
| F-11066 | Prior Authorization / Oxygen Attachment (PA/OA) | DMS | None |
| F-11031 | Prior Authorization / Psychotherapy Attachment (PA/PSYA) | DMS | None |
| F-13393 | Trading Partner 835 Designation | DMS | None |
| F-11038 | Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) | DMS | None |
| F-01067 | HealthCheck Your Child's Speech and Hearing | DMS | None |
| F-11067 | Record of Actual Daily Oxygen Use | DMS | None |
| F-01160 | Acknowledgement of Receipt of Hysterectomy Information | DMS | None |
| F-60287 | Community-Based Residential Facility (CBRF) Initial Licensure Application | DQA | None |
| F-11032 | Prior Authorization / Substance Abuse Attachment (PA/SAA) | DMS | None |
| F-13470 | Claim Form Attachment Cover Page | DMS | None |
| F-00020 | Drug Addition Review Request | DMS | None |
| F-00885 | Specialized Medical Vehicle Insurance Documentation Checklist | DMS | None |
| F-11019 | Prior Authorization / Physician Otological Report (PA/POR) | DMS | None |
| F-11136 | Personal Care Addendum | DMS | None |
| F-01009A | Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under | DMS | None |
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Last Revised: March 26, 2019
