Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.
| Assigned Number | Title | Division |
Other Location |
|---|---|---|---|
| F-11237 | Specialized Medical Vehicle Providers Affidavit | DMS | None |
| F-11307 | Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis | DMS | None |
| F-00659 | Substance Abuse Block Grant Prevention Program / Practice Approval | DCTS | None |
| F-47463E | Paramedic Operational Plan Components | DPH | None |
| F-02638 | Requesting PPS Access During COVID-19 Health Emergency | DMS | None |
| F-11019 | Prior Authorization / Physician Otological Report (PA/POR) | DMS | None |
| F-01710 | Home Health Agency Initial Licensure Checklist | DQA | None |
| F-02538A | CLTS Provider Cost-Based Outlier | DMS | None |
| F-00482 | Comprehensive Community Services (CCS) for Persons with Mental Disorders and Substance Use Disorders Initial Certification Application - Chapter DHS 36 | DQA | None |
| F-10111 | Good Faith Medicaid / BadgerCare Plus Certification | DMS | None |
| F-01571 | Air Quality Measurement Device Maintenance and Calibration Log | DPH | None |
| F-00334 | Money Follows the Person (MFP) - Participant Reporting | DMS | None |
| F-40108 | Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) Program | DPH | None |
| F-02466 | MCO Appeal Log for Family Care, Family Care Partnership, and PACE Programs | DMS | None |
| F-01442D | IRIS Program Disenrollment Letter – Incomplete Functional Screen | DMS | None |
| F-00166 | Service Delivery Discrimination Complaint | DES | None |
| F-22553A | Free In-Service or Educational Training Request | DPH | None |
| F-11092 | Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs | DMS | None |
| F-00020 | Drug Addition Review Request | DMS | None |
| F-01207 | IRIS Fiscal Employer Agent Quality Management Plan | DMS | None |
| F-01221 | WISEWOMAN Screening Activity | DPH | None |
| F-44243A | Congenital Syphilis Case Investigation Report | DPH | None |
| F-16076 | FoodShare Six-Month Report and Instructions | DMS | None |
| F-01556E | IRIS Medicaid Cost Share Letter - Fiscal Employer Agent Transfer | DMS | None |
| F-01068J | General Pediatric Clinic - Preschool Visit | DMS | None |
| F-62607 | Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan | DMS | None |
| F-20919 | Medicaid Waiver Eligibility and Cost Sharing Worksheet | DMS | None |
| F-13147 | Wisconsin Medicaid HIPAA Privacy Restriction Request | DMS | None |
| F-02059 | New Carrier Insurance Disclosure Onboarding | DMS | None |
| F-62166 | Report of Hours Worked - Licensed Practical Nurse / Night | DQA | None |
| F-02681 | Community Engagement Assessment Tool Survey | DPH | None |
| F-01804 | Appointment Results Wisconsin WIC Program | DPH | None |
| F-00923 | Reschedule Lead (PB) Certification Exam | DPH | None |
| F-11077 | Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) | DMS | None |
| F-45021 | Generally Licensed Device Inspection by Mail | DPH | None |
| F-01624 | OARS Alternative to Revocation (ATR) Referral | DCTS | None |
| F-00438 | Community Substance Abuse Services (CSAS) Verification of Criteria - DHS 75.02 (11) | DQA | None |
| F-02106D | Adult Day Care Center – New Provider Certification Application Checklist | DQA | None |
| F-00989N | Other Services / Community and Medical Supports (IFSP) | DMS | None |
| F-00295 | Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs | DMS | None |
| F-02400A | Client Transfer: Assisted Living Facility Capability | DQA | None |
| F-01314 | IRIS Program Employment Checklist | DMS | None |
| F-44771AA | Medicaid Targeted Case Management Fact Sheet - Childhood Lead Poisoning | DPH | None |
| F-21334 | Encounter New User Request | DMS | None |
| F-80479 | Audit Confirmation Request | DES | None |
| F-02817 | Annual Review for Division of Medicaid Services (DMS) Vendors | DMS | None |
| F-02106 | Adult Day Care Center – Applicant Compliance Statement | DQA | None |
| F-02721B | Notice of Medical Remedial Expenses | DPH | None |
| F-01195 | Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo | DMS | None |
| F-16022 | Social Security Number Referral | DMS | None |
Pages
Last Revised: March 23, 2021
