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| Assigned Number | Title | Division |
Other Location |
|---|---|---|---|
| F-02768 | COVID-19 Wasted Vaccine Record | CRT | None |
| F-16035 | Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) | DMS | None |
| F-01068E | General Pediatric Clinic - 9 Month Visit | DMS | None |
| F-62595 | Long-Term Care Facility Feeding Assistant Roster | DQA | None |
| F-13072 | Noncompound Drug Claim | DMS | None |
| F-02059 | New Carrier Insurance Disclosure Onboarding | DMS | None |
| F-00893 | Affidavit of No Social Security Number - EMS Professional License | DPH | None |
| F-62069A | Personal Care Agency Complaint Report | DQA | None |
| F-02577 | Proof of In-Kind Hours | DMS | None |
| F-11051 | Prior Authorization / Vision Services Attachment (PA/VA) | DMS | None |
| F-01804 | Appointment Results Wisconsin WIC Program | DPH | None |
| F-00548 | Mental Health Day Treatment Services for Children Program Application - DHS 40 | DQA | None |
| F-45014 | Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators | DPH | None |
| F-02110A | RCAC: Established Provider Certification / Registration Application | DQA | None |
| F-10161 | Statement of Citizenship and/or Identity | DMS | None |
| F-01621 | Smoking Cessation Data Collection | DCTS | None |
| F-00385 | Nurse Aide Training - Student Waiver Request | DQA | None |
| F-44016 | Asbestos Occupant Protection Plan | DPH | None |
| F-02493 | ForwardHealth Prior Authorization Speech-Generating Device Purchase Recommendation Attachment | DMS | None |
| F-00989M | Justification for Services Provided in Locations Other than Natural Environments (IFSP) | DMS | None |
| F-03037 | Wisconsin Lead-in Water Testing and Remediation (WTR) Initiative | DPH | None |
| F-40019 | Affirmation of Identity, Residency, Income, or Benefit Loss | DPH | None |
| F-02400B | Client Transfer: Labels | DQA | None |
| F-02919 | Vendor Performance Report for Division of Medicaid Services (DMS) | DMS | None |
| F-00250 | Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use | DMS | None |
| F-00054A | Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO | DPH | None |
| F-01309 | IRIS Program Orientation and Enrollment Checklist | DMS | None |
| F-21189 | Rights of Detention | DCTS | None |
| F-01185 | Wisconsin Adult Cystic Fibrosis Program Application | DMS | None |
| F-80479 | Audit Confirmation Request | DES | None |
| F-16001 | Notice of Denial of Benefits/Negative Change in Benefits | DMS | None |
| F-02107 | Family Adult Day Care Center – Applicant Compliance Statement | DQA | None |
| F-01013 | Nurse Aide Training and Competency Test Reimbursement Request | DMS | None |
| F-62470 | Client/Patient/Resident Reportable Death Determination | DQA | None |
| F-02500 | Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care | DPH | None |
| F-11317 | Certification Criteria for Providers Express Enrollment of Pregnant Women in BadgerCare Plus | OIG | None |
| F-01442i | IRIS Program Disenrollment Letter - Cancelled | DMS | None |
| F-00759 | Business Associate Agreement: With Contract | DES | None |
| F-60290 | Community Based Residential Facility (CBRF) Identification of Hazards Request | DQA | None |
| F-11031 | Prior Authorization / Psychotherapy Attachment (PA/PSYA) | DMS | None |
| F-00575 | Notice of Intent to Submit an Application for Tribal Aging and Disability Resource Specialist (ADRS) | DPH | None |
| F-02572 | Prior Authorization/Preferred Drug List (PA/PDL) for Eucrisa and Opzelura | DMS | None |
| F-01601B | ISP Line Item Detail Budget | DCTS | None |
| F-02505 | Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors | DMS | None |
| F-00517 | Community Substance Abuse Services (CSAS) Residential Intoxification Monitoring Service Initial Certification Application - DHS 75.09 | DQA | None |
| F-10130 | Medicaid Presumptive Disability | DMS | None |
| F-00367 | Functional Eligibility Screen for Children's Long-Term Support Programs | DMS | None |
| F-43006 | Health Care Employer Assurance for J-1 Visa Waiver Applications | DPH | None |
| F-00634A | Types and Locations of Early Intervention Records Birth to 3 Program | DMS | None |
| F-00191A | Certified Outpatient Clinic: Request for a School Branch Office | DQA | None |
Pages
Last Revised: June 16, 2022
