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-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-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG
F-11271 Personal Care Provider Addendum DMS
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
F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease DMS
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis DMS
F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis DMS
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis DMS
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG
F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus OIG
F-11318 Enrollment Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-12022 Managed Care Program Provider Appeal DMS
F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model DMS
F-12025 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request DMS
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request DMS
F-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request DMS
F-12029 Managed Care Disenrollment Request DMS
F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions DMS
F-13033 Probate Claims Notice DMS
F-13038 Notice of Intent to File a Lien DMS
F-13039 Estate Recovery Program (ERP) Disclosure DMS
F-13066 Claim Refund DMS
F-13072 Noncompound Drug Claim DMS
F-13073 Compound Drug Claim DMS
F-13074 Pharmacy Special Handling Request DMS

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Last Revised: March 26, 2019