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Data Collection (Forms) Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions.

When you are searching for a form, 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-00020 Drug Addition Review Request DMS English 04/2014 PDF No
F-00020 Drug Addition Review Request DMS English 04/2014 Word No
F-62643 Drug Repository Program Notice of Participation or Withdrawal DQA English 02/2022 Word No
F-62645C Drug Repository Program: Destruction Record DQA English 05/2020 Word No
F-62645B Drug Repository Program: Donation Record DQA English 05/2020 Word No
F-62645 Drug Repository Program: Recipient Record DQA English 05/2020 Word No
F-62645 Drug Repository Program: Recipient Record DQA English 05/2020 PDF No
F-62645A Drug Repository Program: Transfer Record DQA English 05/2020 Word No
F-02891 Durable Medical Equipment Home Accessibility Report DMS English 08/2022 PDF No
F-02891 Durable Medical Equipment Home Accessibility Report DMS English 08/2022 Word No
F-40303 Early Childhood Caries Prevention Screening DPH English 10/2003 PDF No
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP) DMS English 02/2017 Word No
F-00989FS Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP), Spanish DMS Spanish 02/2017 Word No
F-01411 Education - Medication Summary - Part B DPH English 10/2017 Word No
F-01410 Education Summary DPH English 07/2022 PDF 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-00163 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Anti-Obesity Drugs DMS English 04/2023 PDF No
F-00163 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Anti-Obesity Drugs DMS English 04/2023 Word No
F-00163A Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Anti-Obesity Drugs, Instructions DMS English 04/2023 PDF No
F-00238 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents DMS English 07/2023 Word No
F-00238 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents DMS English 07/2023 PDF No
F-00238A Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents, Instructions DMS English 07/2023 PDF No
F-01749 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Insulin - Long-Acting DMS English 07/2021 PDF No
F-01749 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Insulin - Long-Acting DMS English 07/2021 Word No
F-01749A Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Insulin - Long-Acting, Instructions DMS English 07/2021 PDF No
F-00162 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS English 07/2023 Word No
F-00162 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS English 07/2023 PDF No
F-00162A Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids, Instructions DMS English 07/2023 PDF No
F-02505 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS English 07/2022 Word No
F-02505 Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors DMS English 07/2022 PDF No
F-02505A Effective for use before 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors Instructions DMS English 07/2022 PDF No
F-11092 Effective for use before 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2023 Word No
F-11092 Effective for use before 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2023 PDF No
F-11092A Effective for use before 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs, Instructions DMS English 07/2023 PDF No
F-00081 Effective for use before 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine DMS English 01/2024 PDF No
F-00081 Effective for use before 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine DMS English 01/2024 Word No
F-00081A Effective for use before 07/01/2024: Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents – Buprenorphine, Instructions DMS English 01/2024 PDF No
F-00163 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Anti-Obesity Drugs DMS English 06/2024 Word No
F-00163 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Anti-Obesity Drugs DMS English 06/2024 PDF No
F-00163A Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Anti-Obesity Drugs Instructions DMS English 06/2024 PDF No
F-00238 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents DMS English 06/2024 PDF No
F-00238 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents DMS English 06/2024 Word No
F-00238A Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Glucagon-Like Peptide (GLP-1) Agents Instructions DMS English 06/2024 PDF No
F-01749 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Insulins Long-Acting DMS English 06/2024 PDF No
F-01749 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Insulins Long-Acting DMS English 06/2024 Word No
F-01749A Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Hypoglycemics, Insulins Long-Acting Instructions DMS English 06/2024 PDF No
F-00162 Effective for use on and after 07/01/2024: Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids DMS English 06/2024 Word No

Glossary

 
Last revised December 8, 2023