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 Numbersort descending Title Division Other Location
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-11042 Prior Authorization Amendment Request DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 DMS
F-11048 Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission DMS
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) DMS
F-11055 STAT-PA System Instructions DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-11067 Record of Actual Daily Oxygen Use DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds) DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-11090 Mental Health Day Treatment Functional Assessment DMS
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA) DMS
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-11129A Federally Qualified Health Center Cost Report Completion Instructions DMS
F-11129B-H Federally Qualified Health Center Cost Report Forms OIG
F-11130 Federally Qualified Health Center Interim Report DMS
F-11130B Community Health Center Interim Report DMS
F-11133 Personal Care Screening Tool (PCST) DMS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-11136 Personal Care Addendum DMS
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-11240 Case Management Provider Information OIG
F-11245 Family Planning Clinics or Agencies OIG
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS
F-11260 Degree Addendum OIG
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG
F-11271 Personal Care Provider Addendum DMS
F-11285 HealthCheck Screener Affirmation OIG
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis DMS

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Last Revised: March 26, 2019