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-20817 | Assessment Worksheet for Natural Residential Setting | DMS | None |
| F-20224 | Office for the Blind and Visually Impaired Assessment / Plan / Evaluation | DPH | None |
| F-00567 | Emergency Medical Services Complaint | DPH | None |
| F-11240 | Case Management Provider Information | OIG | None |
| F-22565 | Authorization for Recoupment Caretaker Supplement | DMS | None |
| F-20817A | Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses | DMS | None |
| F-11289 | HealthCheck County Outreach Case Management Plan for County | DMS | None |
| F-11245 | Family Planning Clinics or Agencies | OIG | None |
| F-00646 | Emergency Medical Service Training Center Training Permit Eligibility Certification | DPH | None |
| F-20818 | Certification for SSI-E Exceptional Expense Supplement | DMS | None |
| F-00893 | Affidavit of No Social Security Number - EMS Professional License | DPH | None |
| F-11129B-H | Federally Qualified Health Center Cost Report Forms | OIG | None |
| F-00569 | Request for Waiver of Administrative Rule for Licensure | DPH | None |
| F-16015 | Notice of Approval of Benefits/Positive Change in Benefits | DMS | None |
| F-02538A | CLTS Provider Cost-Based Outlier | DMS | None |
| F-11260 | Degree Addendum | OIG | None |
| F-11078 | Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets | DMS | None |
| F-44819 | Farmers Market Nutrition Program (FMNP) - Application for Farm Stand | DPH | None |
| F-11039 | Prior Authorization / Spell of Illness Attachment (PA/SOIA) | DMS | None |
| F-11305 | Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease | DMS | None |
| F-47479 | Trauma Care Facility Classification Application | DPH | None |
| F-11022 | Rural Health Clinic Statistical Data | DMS | None |
| F-47470 | Change of EMS Medical Director | DPH | None |
| F-02538 | Children’s Long-Term Support Waiver Program—Outlier Rate Request | DMS | None |
| F-01359 | Historical Earnings Verification Request | DMS | None |
| F-10146 | Employer Verification of Earnings | DMS | None |
| F-10093 | Wisconsin Medicaid and BadgerCare Plus Overpayment Notice | DMS | None |
| F-01302 | Weekly Driver's Vehicle Inspection Report | DMS | None |
| F-01165 | Newborn Report | DMS | None |
| F-10184 | BadgerCare Plus Former Foster Care Youth (FFCY) | DMS | None |
| F-01134 | Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit | DMS | None |
| F-10185 | BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication | DMS | None |
| F-01161 | Abortion Certification Statements | DMS | None |
| F-01566A | IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care | DMS | None |
| F-00114 | EMS Service Director License Proxy for Individuals | DPH | None |
| F-00568 | EMS Board Sub-Committee Appointment Application | DPH | None |
| F-01620 | Opening Avenues to Reentry Success (OARS) Informed Consent for Mental Health Evaluation, Treatment and Community Reintegration Services | DCTS | None |
| F-01068H | General Pediatric Clinic - 18 Month Visit | DMS | None |
| F-01068B | General Pediatric Clinic - 6 to 8 Week Visit | DMS | None |
| F-01068i | General Pediatric Clinic - 24 Month Visit | DMS | None |
| F-01068C | General Pediatric Clinic - 4 Month Visit | DMS | None |
| F-01068J | General Pediatric Clinic - Preschool Visit | DMS | None |
| F-01068D | General Pediatric Clinic - 6 Month Visit | DMS | None |
| F-01068K | General Pediatric Clinic - Elementary School Visit | DMS | None |
| F-01068E | General Pediatric Clinic - 9 Month Visit | DMS | None |
| F-01068L | General Pediatric Clinic - Teenager Visit | DMS | None |
| F-01068F | General Pediatric Clinic - 12 Month Visit | DMS | None |
| F-01068M | Confidential Health Survey | DMS | None |
| F-01068G | General Pediatric Clinic - 15 Month Visit | DMS | None |
| F-01068A | General Pediatric Clinic - 3 to 4 Week Visit | DMS | None |
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Last Revised: March 26, 2019
