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-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
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS
F-13146 HIPAA Privacy Revocation of Authorization DMS
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS
F-13148 HIPAA Privacy Access Request DMS
F-13149 HIPAA Privacy Accounting Request DMS
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS
F-13151 HIPAA Privacy Amendment Request DMS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request DMS
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request DMS
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request DMS
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request DMS
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request DMS
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint DMS
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization DMS
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request DMS
F-13393 Trading Partner 835 Designation DMS

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Last Revised: March 26, 2019