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-11021 | Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) | DMS | None |
| F-00885 | Specialized Medical Vehicle Insurance Documentation Checklist | DMS | None |
| F-11136 | Personal Care Addendum | DMS | None |
| F-00020 | Drug Addition Review Request | DMS | None |
| F-01009A | Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under | DMS | None |
| F-00280 | Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other | DMS | None |
| F-00239 | Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips | DMS | None |
| F-01009B | Wisconsin Medicaid Election of Hospice Benefit for Members 21 and Older | DMS | None |
| F-00281 | Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents | DMS | None |
| F-00142 | Prior Authorization / Drug Attachment for Synagis® | 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 |
| F-11019 | Prior Authorization / Physician Otological Report (PA/POR) | DMS | None |
| F-11034 | Prior Authorization / "J" Code Attachment (PA/JCA) | DMS | None |
| F-11051 | Prior Authorization / Vision Services Attachment (PA/VA) | DMS | None |
| F-01176 | Prior Authorization Fax Cover Sheet | DMS | None |
| F-01411 | Education - Medication Summary - Part B | DPH | None |
| F-11020 | Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) | DMS | None |
| F-11035 | Prior Authorization Dental Request Form (PA/DRF) | DMS | None |
| F-11054 | Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) | DMS | None |
| F-11042 | Prior Authorization Amendment Request | DMS | None |
| F-01413 | Post-Assessment Questionnaire | DPH | None |
| F-11030 | Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) | DMS | None |
| F-43026 | Wisconsin Donor Registry User Access Request | DPH | None |
| F-01414 | How Did We Do? | DPH | None |
| F-13074 | Pharmacy Special Handling Request | DMS | None |
| F-11016 | Prior Authorization Physician Attachment (PA/PA) | DMS | None |
| F-00971 | Request to Remove Yellow Fever Vaccine Vaccination Center | DPH | None |
| F-01410 | Education - Medication Summary - Part A | DPH | None |
| F-11018 | Prior Authorization Request Form (PA/RF) | DMS | None |
| F-01197 | Certification of Need for Specialized Medical Vehicle Transportation | DMS | None |
| F-00983 | Aggregate Data Request - Wisconsin Cancer Reporting System (WCRS) | DPH | None |
| F-44151 | Acute and Communicable Disease Case Report | DPH | None |
| F-02544 | Nursing Home Immediate Jeopardy (IJ) Removal Plan | DQA | None |
| F-00047 | Designated Asbestos Coordinator | DPH | None |
| F-01999A | Retired Senior Volunteer Program: State Match Funding Application | DPH | None |
| F-01999B | Senior Companion Program: State Match Funding Application | DPH | None |
| F-01999 | Foster Grandparent Program: State Match Funding Application | DPH | None |
| F-00539 | County Waiver Agency Support and Service Coordination (SSC) Rates | DMS | None |
| F-02000 | ADRC/Tribal ADRS/Aging System User: Access/Delete/Change | DPH | None |
| F-00576 | Tribal Aging and Disability Resource Specialist (TADRS) Application | DPH | None |
| F-00053 | Notice of Intent to Submit an Application (ADRC) | DPH | None |
| F-00614 | Physician, Physician Assistant, and Registered Nurse Equivalency Application | DPH | None |
| F-00576A | Tribal Aging and Disability Resource Specialist (TADRS) Annual Budget | DPH | None |
| F-44444 | WIC Vendor Supply Order | DPH | None |
| F-01398 | WISEWOMAN Client Home Blood Pressure Monitoring Agreement | DPH | None |
| F-01225 | WISEWOMAN Healthy Behavior Encounter | DPH | None |
| F-11097 | Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents | DMS | None |
| F-11271 | Personal Care Provider Addendum | DMS | None |
| F-20224 | Office for the Blind and Visually Impaired Assessment / Plan / Evaluation | DPH | None |
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Last Revised: March 26, 2019
