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 Number Titlesort descending Division Other Location
F-11096 Prior Authorization / Care Plan Attachment (PA/CPA) DMS
F-11040 Prior Authorization / Child / Adolescent Day Treatment Attachment (PA/CADTA) DMS
F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) DMS
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-11049 Prior Authorization / Drug Attachment (PA/DGA) DMS
F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs DMS
F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips DMS
F-00142 Prior Authorization / Drug Attachment for Synagis® DMS
F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) DMS
F-11054 Prior Authorization / Enteral Nutrition Formula Attachment (PA/ENFA) DMS
F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) DMS
F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) DMS
F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) DMS
F-11033 Prior Authorization / Mental Health and/or Substance Abuse Evaluation Attachment (PA / EA) DMS
F-11066 Prior Authorization / Oxygen Attachment (PA/OA) DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-11075 Prior Authorization / Preferred Drug List (PA/PDL) Exemption Request 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-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-00281 Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents DMS
F-11078 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets DMS
F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS
F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents DMS
F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) DMS
F-02567 Prior Authorization / Residential Substance Use Disorder Treatment Attachment (PA/RSUD) DMS
F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) DMS
F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) DMS
F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) DMS
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS
F-11051 Prior Authorization / Vision Services Attachment (PA/VA) DMS
F-11042 Prior Authorization Amendment Request DMS
F-11035 Prior Authorization Dental Request Form (PA/DRF) DMS
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids DMS
F-00556 Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger DMS
F-01952 Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA DMS
F-11304 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis DMS
F-01950 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn’s Disease and Ulcerative Colitis DMS
F-11306 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriasis DMS
F-01951 Prior Authorization Drug Attachment for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), and Psoriatic Arthritis DMS
F-02666 Prior Authorization Drug Attachment for Headache Agents, Acute Treatment DMS
F-02667 Prior Authorization Drug Attachment for Headache Agents, Preventative Treatment DMS
F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents DMS
F-00238 Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents DMS
F-01749 Prior Authorization Drug Attachment for Hypoglycemics, Insulin – Long-Acting DMS
F-00162 Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS
F-02505 Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS
F-00805 Prior Authorization Drug Attachment for Multiple Sclerosis (MS) Agents DMS
F-02537 Prior Authorization Drug Attachment for Non-Preferred Stimulants, Related Agents - Wake Promoting DMS

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Last Revised: March 23, 2021