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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-01162A Completion Instructions DMS English 02/2009 PDF No
F-00079 Completion Instructions DMS English 01/2017 PDF No
F-11020A Completion Instructions DMS English 02/2016 PDF No
F-11032A Completion Instructions DMS English 10/2008 PDF No
F-00701 Completion Instructions DMS English 08/2013 PDF No
F-00080 Completion Instructions DMS English 07/2015 PDF No
F-01197A Completion Instructions DMS English 06/2009 PDF No
F-01050 Completion Instructions DMS English 04/2022 PDF No
F-11027 Completion Instructions DMS English 10/2016 PDF No
F-11031A Completion Instructions DMS English 10/2008 PDF No
F-00239 Completion Instructions DMS English 07/2015 PDF No
F-11021A Completion Instructions DMS English 11/2008 PDF No
F-00694 Completion Instructions DMS English 07/2015 PDF No
F-13073 Compound Drug Claim DMS English 04/2017 Word No
F-13073 Compound Drug Claim DMS English 04/2017 PDF No
F-13073A Compound Drug Claim: Completion Instructions DMS English 04/2017 PDF No
F-01270 Comprehensive Community Services Non-Traditional Approval DMS English 07/2014 PDF No
F-01270 Comprehensive Community Services Non-Traditional Approval DMS English 07/2014 Word No
F-01068M Confidential Health Survey DMS English 08/2019 PDF No
F-01068M Confidential Health Survey DMS English 08/2019 Word No
F-01068MS Confidential Health Survey, Spanish DMS Spanish 08/2019 PDF No
F-01068MS Confidential Health Survey, Spanish DMS Spanish 08/2019 Word No
F-01164 Consent for Sterilization DMS English 10/2008 PDF No
F-01164 Consent for Sterilization DMS English 10/2008 Word No
F-01164S Consent for Sterilization, Spanish DMS Spanish 10/2008 Word No
F-01164S Consent for Sterilization, Spanish DMS Spanish 10/2008 PDF No
F-01182 Declaration of Supervision for Nonbilling Providers DMS English 07/2012 PDF No
F-01182 Declaration of Supervision for Nonbilling Providers DMS English 07/2012 Word No
F-10193 Divestment Penalty and Undue Hardship Notice Plus Waiver Request DMS English 08/2021 PDF No
F-10193S Divestment Penalty and Undue Hardship Notice Plus Waiver Request, Spanish DMS Spanish 08/2021 PDF No
F-00020 Drug Addition Review Request DMS English 04/2014 PDF No
F-00020 Drug Addition Review Request DMS English 04/2014 Word No
F-00180C Effective before 09/09/2024: Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS English 05/2024 Word No
F-00180C Effective before 09/09/2024: Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals, Spanish DMS Spanish 05/2024 Word No
F-00079 Effective for use before 07/01/2019: Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil DMS English 01/2019 PDF No
F-00079 Effective for use before 07/01/2019: Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil Instructions DMS English 01/2019 PDF No
F-03250 Effective on or after 09/09/2024: Adult Long-Term Care (LTC) Waiver Provider Application Information and Instructions DMS English 05/2024 PDF No
F-03250 Effective on or after 09/09/2024: Adult Long-Term Care (LTC) Waiver Provider Application Information and Instructions DMS English 05/2024 Word No
F-03203 Effective on or after 09/09/2024: Disenrollment of Adult Long-Term Care (LTC) Waiver Program and Services DMS English 05/2024 Word No
F-03246 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 05/2024 Word No
F-03246 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 05/2024 PDF No
F-03243 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 05/2024 PDF No
F-03243 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 05/2024 Word No
F-03244 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 05/2024 Word No
F-03244 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 05/2024 PDF No
F-03245 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 05/2024 Word No
F-03245 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 05/2024 PDF No
F-03234 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 05/2024 Word No
F-03234 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 05/2024 PDF No
F-03235 Effective on or after 09/09/2024: Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 05/2024 PDF No

Glossary

 
Last revised January 24, 2023