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-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS
F-11136 Personal Care Addendum DMS
F-11134 Personal Care Prior Authorization Provider Acknowledgement DMS
F-11133 Personal Care Screening Tool (PCST) DMS
F-11130 Tribal and Out-of-State Federally Qualified Health Center Interim Report DMS
F-11129B-H Tribal and Out-of-State Federally Qualified Health Center Cost Report Forms OIG
F-11129A Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions DMS
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA) DMS
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-11090 Mental Health Day Treatment Functional Assessment DMS
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-11081 Rural Health Clinic Provider Staff Encounters DMS
F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based Rural Health Clinics (Affiliated Hospital Having More Than 50 Beds) DMS
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request DMS
F-11067 Record of Actual Daily Oxygen Use DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-11055 STAT-PA System Instructions DMS
F-11054 Prior Authorization / Enteral Nutrition Formula Attachment (PA/ENFA) DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-11049 Prior Authorization / Drug Attachment (PA/DGA) 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-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-11042 Prior Authorization Amendment Request DMS
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) DMS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) DMS
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-11027 Rural Health Clinic Quarterly Cost Report DMS
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS
F-11023 Rural Health Clinic (RHC) Reclassification and Adjustment of Trial Balance Expenses DMS
F-11022 Rural Health Clinic Statistical Data DMS
F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) DMS
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS

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Last Revised: March 23, 2021