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 Number Titlesort ascending Division Other Location
F-01018 Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers DMS
F-01313 Register to Reschedule Lead (Pb) Certification Exam DPH
F-00688 Referral to Wisconsin Birth-3 Program DMS
F-22469 Referral for Services from the Office for the Blind and Visually Impaired (OBVI) DPH
F-00192 Referral / Communication Wisconsin WIC Program DPH
F-01555 Reference Sheet – IRIS Consultant Agency (ICA) Assignments by Area of Responsibility DMS
F-01555A Reference Sheet – Fiscal Employer Agent (FEA) Assignments by Area of Responsibility DMS
F-01391 Recovery Oriented System Indicator (ROSI) Adult Data Workbook DCTS
F-00634B Records Access Log, Birth to 3 Program DMS
F-02284 Record of School Employee Examination DPH
F-11067 Record of Actual Daily Oxygen Use DMS
F-45019 Reciprocity Privileges Checklist DPH
F-80900A Receivables Quarterly Report DES
F-80900 Receivables Annual Report DES
F-02250 Quarterly Program Integrity Report OIG
F-16011 Quality Assurance (QA) Sample Checklist DMS
F-00945 Purchase of Service Audit Waiver Request / Risk Identification and Assessment Worksheet OS
F-01924 Public Comment on Rulemaking Project OLC
F-00917 Provider Enrollment Application Process DMS
F-16026 Prosecution Diversion Agreement DMS
F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels DPH
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-21225Ai Program Participation System (PPS): B-3 Module, Deskcard DMS
F-21225 Program Participation System (PPS): B-3 Module DMS
F-21225A Program Participation System (PPS): B-3 Module DMS
F-02167 Program Participation System (PPS) PORTAL Report Feedback DCTS
F-01278 Program Participation System (PPS) Employment Questions DMS
F-01279 Program Participation System (PPS) Employment Interview DMS
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs) OIG
F-80881 Profile ID Request (CARS) DES
F-13033 Probate Claims Notice DMS
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS
F-00315C Prior Notice and Consent for Evaluation and Assessment DMS
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine DMS
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS
F-00805 Prior Authorization/Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators DMS
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS
F-00238 Prior Authorization/Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents DMS
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids DMS
F-11083 Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA) DMS
F-00787 Prior Authorization Requirements Exemption Request for Computed Tomography (CT), Magnetic Resonance (MR), and Magnetic Resonance Elastography (MRE) Imaging Services DMS
F-11018 Prior Authorization Request Form (PA/RF) 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-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-01176 Prior Authorization Fax Cover Sheet DMS

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Last Revised: March 26, 2019