Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Numbersort ascending Title Division Other Location
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request DMS
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure DMS
F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization DMS
F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request DMS
F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint DMS
F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request DMS
F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request DMS
F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request DMS
F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request DMS
F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure DMS
F-13152 Wisconsin Medicaid HIPAA Privacy Complaint DMS
F-13151 HIPAA Privacy Amendment Request DMS
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS
F-13149 HIPAA Privacy Accounting Request DMS
F-13148 HIPAA Privacy Access Request DMS
F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request DMS
F-13146 HIPAA Privacy Revocation of Authorization DMS
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS
F-13074 Pharmacy Special Handling Request DMS
F-13073 Compound Drug Claim DMS
F-13072 Noncompound Drug Claim DMS
F-13066 Claim Refund DMS
F-13038 Notice of Intent to File a Lien (Paper Only. Follow link to order paper copy.) DMS
F-13033 Probate Claims Notice DMS
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-12029 Managed Care Disenrollment Request DMS
F-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request DMS
F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request DMS
F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request DMS
F-12025 Wisconsin BadgerCare Plus HMO Enrollment Choice DMS
F-12024 Wisconsin Medicaid HMO Enrollment Choice DMS
F-12022 Managed Care Program Provider Appeal DMS
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus OIG
F-11317 Certification Criteria for Providers Express Enrollment of Pregnant Women in BadgerCare Plus OIG
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification OIG
F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis 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-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis 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-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis DMS
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG
F-11289 HealthCheck County Outreach Case Management Plan for County DMS
F-11271 Personal Care Provider Addendum DMS
F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification OIG
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS
F-11237 Specialized Medical Vehicle Providers Affidavit DMS
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS

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Last Revised: March 23, 2021