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-00154 | Wisconsin Consultative Examination Inquiry | DMS | None |
| F-00161 | Caregiver Misconduct Reporting Requirements Worksheet | DQA | None |
| F-00161A | Flowchart of Entity Investigation and Reporting Requirements for Caregiver Misconduct and Injuries of Unknown Source | DQA | None |
| F-00162 | Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids | DMS | None |
| F-00163 | Prior Authorization / Drug Attachment for Anti-Obesity Drugs | DMS | None |
| F-00164 | Civil Rights Compliance Plan | OLC | None |
| F-00165 | Civil Rights Compliance Letter of Assurance | OLC | None |
| F-00166 | Service Delivery Discrimination Complaint | DES | None |
| F-00169 | Opting Out of Local Education Agency (LEA) and State Education Agency (SEA) Notification | DMS | None |
| F-00171 | Lead Company Application | DPH | None |
| F-00176 | Civil Money Penalty Funds Project Proposal | DQA | None |
| F-00180C | Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals | DMS | None |
| F-00191 | Certified Outpatient Clinic: Request for a Branch Office | DQA | None |
| F-00191A | Certified Outpatient Clinic: Request for a School Branch Office | DQA | None |
| F-00192 | Referral / Communication Wisconsin WIC Program | DPH | None |
| F-00193 | Pediatric Referral / Communication Wisconsin WIC Program | DPH | None |
| F-00194 | Prior Authorization Drug Attachment for Antiemetics, Cannabinoids | DMS | None |
| F-00195 | IDEA (Individuals with Disabilities Education Act) State Complaint - WI Birth to 3 Program | DMS | None |
| F-00201 | Occupant Protection Plan Checklist for Lead-Based Paint Activities | DPH | None |
| F-00202 | Individual Service Plan - Community Recovery Services (CRS) | DCTS | None |
| F-00203 | Community Recovery Services (CRS) - County / Tribal Agency Application | DCTS | None |
| F-00212 | Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment | DMS | None |
| F-00219 | Self-Employment Income Report: Farm Business | DMS | None |
| F-00221 | Family Care / IRIS Member Requested Disenrollment or Transfer and Instructions | DPH | None |
| F-00233 | Renewal Summary Letter | DMS | None |
| F-00236 | Request for a State Fair Hearing - MCO | DMS | None |
| F-00236A | Request for a State Fair Hearing - ADRC | DPH | None |
| F-00236B | Request for a State Fair Hearing - IRIS | DMS | None |
| F-00238 | Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents | DMS | None |
| F-00239 | Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips | DMS | None |
| F-00246 | Employer Health Insurance Verification Individual Follow-Up Health Insurance Information | DMS | None |
| F-00250 | Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use | DMS | None |
| F-00251 | Mental Health Block Grant Community Aids Allocation Report | DCTS | None |
| F-00258 | Functional Eligibility Screen - Mental Health and AODA (Co-Occurring) Services | DCTS | None |
| F-00260 | Community Recovery Services - Service Plan Packet Quality Review Results | DCTS | None |
| F-00261 | Personal Care Agency Personnel Record Review | DQA | None |
| F-00262 | Personal Care Agency Application Materials Checklist | DQA | None |
| F-00262A | Personal Care Agency Application Regulatory Guidance Checklist | DQA | None |
| F-00263 | Personal Care Agency Record Review | DQA | None |
| F-00264 | Personal Care Agency Surveyor Guide | DQA | None |
| F-00273 | Behavioral Health Services Initial Certification Application - DHS 94 Patient Rights and Resolution of Patient Grievances | DQA | None |
| F-00276 | Behavioral Health Services Recertification Application - DHS 94 Patients Rights and Resolution of Patient Grievances DHS 92 Confidentiality of Treatment Records | DQA | None |
| F-00281 | Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents | DMS | None |
| F-00295 | Medical and Remedial Expenses Checklist for Medicaid Long-Term Care Waiver Programs | DMS | None |
| F-00301 | 2009 Wisconsin ACT 318 High Cost Mental Health Fund Application | DCTS | None |
| F-00302 | Community Substance Abuse Services (CSAS) Outpatient Clinic Recertification Application - DHS 75.13 Outpatient Treatment Service | DQA | None |
| F-00303 | 2009 ACT 198 Request for Approval to Issue Identification Cards - Access to Toilet Facilities in Retail Establishments | DPH | None |
| F-00309 | Medicaid Provider Report | DQA | None |
| F-00311 | Nursing Home MDS 3.0 Section Q Referral | DQA | None |
| F-00312 | Wisconsin Medicaid CRS Benefit Provider Agreement and Acknowledgement of Terms of Participation | DCTS | None |
Pages
Last Revised: March 26, 2019
