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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-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 Word No
F-02885 Request for Institution of Mental Disease Determination for Children’s Residential Settings DMS English 10/2021 PDF 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 PDF No
F-01149 Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements DMS English 07/2012 Word 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-11025A Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs Instructions 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-11026A Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Completion Instructions DMS English 04/2014 PDF 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-11027A Rural Health Clinic Quarterly Cost Report Completion Instructions DMS English 10/2016 PDF No
F-11022 Rural Health Clinic Statistical Data DMS English 10/2016 PDF No
F-11022 Rural Health Clinic Statistical Data DMS English 10/2016 Word 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-00219A Self-Employment Income Report: Farm Business Instructions DMS English 06/2019 PDF No
F-00219ACM Self-Employment Income Report: Farm Business Instructions, Chinese (Simplified) DMS Chinese (Simplified) 06/2019 PDF No
F-00219AH Self-Employment Income Report: Farm Business Instructions, Hmong DMS Hmong 06/2019 PDF No
F-00219AS Self-Employment Income Report: Farm Business Instructions, Spanish DMS Spanish 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
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-01050A Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions 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-00030A 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

Glossary

 
Last revised January 24, 2023