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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-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS English 03/2014 Word No
F-11237 Specialized Medical Vehicle Providers Affidavit DMS English 01/2022 PDF No
F-11237 Specialized Medical Vehicle Providers Affidavit DMS English 01/2022 Word No
F-01050 Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification DMS English 04/2022 PDF No
F-01306 Spousal Impoverishment Income Allocation Worksheet DMS English 07/2014 PDF No
F-11055 STAT-PA System Instructions DMS English 07/2015 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS English 04/2017 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS English 04/2017 Word No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request: Completion Instructions DMS English 04/2017 PDF No
F-00100 State Vital Records Birth Certificate Request Letter DMS English 06/2019 Word No
F-10161 Statement of Citizenship and/or Identity DMS English 07/2018 PDF No
F-10154 Statement of Identity for Children Under 18 Years of Age DMS English 07/2008 PDF No
F-10154DA Statement of Identity for Children Under 18 Years of Age, Dari DMS Dari (Afghan Persian) 07/2008 PDF No
F-10154H Statement of Identity for Children Under 18 Years of Age, Hmong DMS Hmong 07/2008 PDF No
F-10154PA Statement of Identity for Children Under 18 Years of Age, Pashto DMS Pashto 07/2008 PDF No
F-10154R Statement of Identity for Children Under 18 Years of Age, Russian DMS Russian 07/2008 PDF No
F-10154S Statement of Identity for Children Under 18 Years of Age, Spanish DMS Spanish 07/2008 PDF No
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS English 06/2023 PDF No
F-00685 Statement of Tribal Affiliation DMS English 06/2023 PDF No
F-16031 Student Aid and Expense Worksheet DMS English 07/2008 PDF No
F-16021 Student Financial Aid Report DMS English 07/2008 PDF No
F-00098 Summary of Information Letter DMS English 06/2019 PDF No
F-01305 Supplemental Security Income-Related Determination DMS English 03/2017 PDF No
F-13047 Timely Filing Appeals Request and Instructions DMS English 08/2015 Word No
F-13047 Timely Filing Appeals Request and Instructions DMS English 08/2015 PDF No
F-11130 Tribal and Out-of-State Federally Qualified Health Center DMS English 01/2021 Excel No
F-11129A Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions DMS English 01/2021 PDF No
F-11129 Tribal and Out-of-State Federally Qualified Health Center Cost Report Forms OIG English 01/2021 Excel No
F-11130A Tribal and Out-of-State Federally Qualified Health Center, Instructions DMS English 01/2021 PDF No
F-10189 Undue Hardship Bed Hold Notice DMS English 04/2017 Word No
F-10188 Undue Hardship Waiver Decision for Facility DMS English 04/2017 Word No
F-02919 Vendor Performance Report for Division of Medicaid Services (DMS) DMS English 01/2024 Word No
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement DMS English 08/2019 PDF No
F-01017 Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement DMS English 08/2019 Word No
F-10162 Verification of Veterans Benefits DMS English 12/2022 PDF No
F-01302 Weekly Driver's Vehicle Inspection Report DMS English 09/2019 Word No
F-01302 Weekly Driver's Vehicle Inspection Report DMS English 09/2019 PDF No
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request DMS English 12/2013 Word No
F-00916 Wisconsin AIDS Drug Assistance Program / Wisconsin Chronic Disease Program / Wisconsin Well Woman Program Provider File Update Request DMS English 12/2013 PDF No
F-00154 Wisconsin Consultative Examination Inquiry DMS English 06/2019 Word No
F-10141 Wisconsin Funeral and Cemetery Aids Program Application DMS English 05/2022 PDF No
F-10144 Wisconsin Life Insurance Inquiry DMS English 05/2019 Word No
F-11048 Wisconsin Medicaid - 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 English 02/2009 PDF No
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS English 08/2019 Word No
F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge DMS English 08/2019 PDF No
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS English 09/2019 Word No
F-01003 Wisconsin Medicaid Certification of Public Expenditures DMS English 07/2008 PDF No
F-13150 Wisconsin Medicaid Confidential or Alternative Communication Request DMS English 04/2019 PDF No
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS English 12/2010 Word No
F-01009A Wisconsin Medicaid Election of Hospice Benefit for Members 20 and Under DMS English 12/2010 PDF No

Glossary

 
Last revised January 24, 2023