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Medicaid Forms

Below is a list of all Medicaid forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 Word No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS English 05/2019 PDF No
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS English 05/2019 Word No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 Word No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 PDF No
F-13033 Probate Claims Notice DMS English 05/2021 PDF No
F-02577 Proof of In-Kind Hours DMS English 06/2023 PDF No
F-02577H Proof of In-Kind Hours, Hmong DMS Hmong 06/2023 PDF No
F-02577S Proof of In-Kind Hours, Spanish DMS Spanish 06/2023 PDF No
F-00917 Provider Enrollment Application Process DMS English 12/2013 HTML No
F-02250 Quarterly Program Integrity Report OIG English 05/2023 Excel No
F-11067 Record of Actual Daily Oxygen Use DMS English 07/2012 PDF No
F-11067 Record of Actual Daily Oxygen Use DMS English 07/2012 Word No
F-11067A Record of Actual Daily Oxygen Use: Completion Instructions DMS English 07/2012 PDF No
F-00233 Renewal Summary Letter DMS English 08/2019 Word No
F-00233H Renewal Summary Letter (Hmong) DMS Hmong 08/2019 Word No
F-00233S Renewal Summary Letter (Spanish) DMS Spanish 08/2019 Word No
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS English 09/2019 Word No
F-01134 Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit DMS English 09/2019 PDF No
F-02885 Request for Institution of Mental Disease Determination for Children’s Residential Settings DMS English 10/2021 PDF No
F-02885 Request for Institution of Mental Disease Determination for Children’s Residential Settings DMS English 10/2021 Word No
F-01020A Request for Nursing Home Care Determination Completion Instructions DMS English 02/2017 PDF No
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS English 07/2012 Word No
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS English 07/2012 PDF No
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS English 04/2009 Word No
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS English 04/2009 PDF No
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS English 04/2009 PDF No
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS English 04/2009 Word No
F-11081 Rural Health Clinic Provider Staff Encounters DMS English 10/2016 Excel No
F-11027 Rural Health Clinic Quarterly Cost Report DMS English 10/2016 Excel No
F-11022 Rural Health Clinic Statistical Data DMS English 10/2016 Word No
F-11022 Rural Health Clinic Statistical Data DMS English 10/2016 PDF No
F-00107 Self-Employment Income Report DMS English 06/2019 PDF No
F-00107CM Self-Employment Income Report, Chinese (Simplified) DMS Chinese (Simplified) 06/2019 PDF No
F-00107H Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107S Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-00219 Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
F-00219CM Self-Employment Income Report: Farm Business, Chinese (Simplified) DMS Chinese (Simplified) 06/2019 PDF No
F-00219H Self-Employment Income Report: Farm Business, Hmong DMS Hmong 06/2019 PDF No
F-00219S Self-Employment Income Report: Farm Business, Spanish DMS Spanish 06/2019 PDF No
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS English 03/2024 PDF No
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS English 02/2017 Word No
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS English 04/2024 PDF No
F-16022 Social Security Number Referral DMS English 07/2008 PDF No
F-16022H Social Security Number Referral, Hmong DMS Hmong 07/2008 PDF No
F-16022S Social Security Number Referral, Spanish DMS Spanish 07/2008 PDF No
F-11296 Specialized Medical Vehicle (SMV) Transportation Service Informational OIG English 07/2012 PDF No
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS English 03/2014 PDF No

Glossary

 
Last revised January 24, 2023