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-45010B Training, Experience and Preceptor Attestation - B (Authorized User - Written Directive Not Required) DPH
F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy DPH
F-45021 Generally Licensed Device Inspection by Mail DPH
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS
F-62470 Client/Patient/Resident Reportable Death Determination DQA
F-00740 Client/Patient/Resident Reportable Death: Quality Improvement Event Analysis Summary DQA
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-44771AA Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning DPH
F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels DPH
F-01186 Wisconsin Chronic Renal Disease Program Application DMS
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-01168 Special Payment Rate Request for Ventilator-Dependent or Brain Injury Cases DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-60945 Adult Family Home Initial Licensure Application DQA
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-01170 Written Correspondence Inquiry DMS
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services DMS
F-60947 Adult Day Care Initial Certification Checklist DQA
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-45015 Application for Radioactive Material License for Broad Scope DPH
F-01199 Optional School-Based Services Activity Medication Administration DMS
F-13066 Claim Refund DMS
F-62380 Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application DQA
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-01182 Declaration of Supervision for Nonbilling Providers DMS
F-05034 Certification of Birth Facts for Birth Certificate Amendment from Physician, Hospital, School, Census, Clinic, Nursery, Etc. DPH
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-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources DPH
F-62418 Adult Day Care Initial Certification Application DQA
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-13393 Trading Partner 835 Designation DMS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-01067 HealthCheck Your Child's Speech and Hearing DMS
F-11067 Record of Actual Daily Oxygen Use DMS
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-60287 Community-Based Residential Facility (CBRF) Initial Licensure Application DQA
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
F-13470 Claim Form Attachment Cover Page DMS
F-00020 Drug Addition Review Request DMS
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-11136 Personal Care Addendum DMS
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS

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Last Revised: March 26, 2019