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-10192 Medicaid Annuity Information - Disclosure DMS
F-10193 Undue Hardship Waiver Request DMS
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-11018 Prior Authorization Request Form (PA/RF) DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS
F-11022 Rural Health Clinic Statistical Data DMS
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS
F-11027 Rural Health Clinic Quarterly Cost Report DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
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 Formula Attachment (PA/ENFA) 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

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Last Revised: March 26, 2019