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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-00212A Prior Authorization/Intensive In-Home Mental Health and Substance Abuse Services Assessment and Recovery/Treatment Plan Attachment Instructions DMS English 12/2019 PDF No
F-03327 Prior Authorization/Pediatric Hospital Bed (PA/PHB) DMS English 11/2024 PDF No
F-03327 Prior Authorization/Pediatric Hospital Bed (PA/PHB) DMS English 11/2024 Word No
F-03327A Prior Authorization/Pediatric Hospital Bed (PA/PHB), Instructions DMS English 11/2024 PDF No
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 PDF No
F-11034 Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) DMS English 07/2022 Word No
F-11034A Prior Authorization/Physician-Administered Drug Attachment (PA/PAD) Instructions DMS English 07/2022 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical DMS English 10/2024 Word No
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 PDF No
F-11075 Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request DMS English 07/2023 Word No
F-11075A Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, Instructions DMS English 07/2023 PDF No
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 01/2017 PDF No
F-01674 Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa DMS English 01/2017 Word No
F-01674A Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Hidradenitis Suppurativa Completion Instructions DMS English 01/2017 PDF No
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS English 04/2021 PDF No
F-02433 Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex DMS English 04/2021 Word No
F-02433A Prior Authorization/Preferred Drug List (PA/PDL) for Epidiolex, Instructions DMS English 04/2021 PDF No
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2024 Word No
F-11092 Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs DMS English 07/2024 PDF No
F-11092A Prior Authorization/Preferred Drug List (PA/PDL) for Growth Hormone Drugs Instructions DMS English 07/2024 PDF No
F-02668 Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable DMS English 07/2020 Word No
F-02668 Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable DMS English 07/2020 PDF No
F-02668A Prior Authorization/Preferred Drug List (PA/PDL) for Headache Agents, Triptans Non-Injectable Instructions DMS English 07/2020 PDF No
F-02572 Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical DMS English 10/2024 PDF No
F-02572A Prior Authorization/Preferred Drug List (PA/PDL) for Immunomodulators, Atopic Dermatitis – Topical, Instructions DMS English 10/2024 PDF No
F-00622A Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Injectable Completion Instructions DMS English 07/2015 PDF No
F-00280A Prior Authorization/Preferred Drug List (PA/PDL) for Migraine Agents, Other Completion Instructions DMS English 07/2015 PDF No
F-00079A Prior Authorization/Preferred Drug List (PA/PDL) for Modafinil and Nuvigil Completion Instructions DMS English 01/2017 PDF No
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS English 01/2017 PDF No
F-01672 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants DMS English 01/2017 Word No
F-01672A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Preferred Stimulants, Instructions DMS English 01/2022 PDF No
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS English 01/2018 PDF No
F-11077 Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) DMS English 01/2018 Word No
F-11077A Prior Authorization/Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Instructions DMS English 01/2022 PDF No
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 07/2024 Word No
F-00081 Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine DMS English 07/2024 PDF No
F-00081A Prior Authorization/Preferred Drug List (PA/PDL) for Opioid Dependency Agents—Buprenorphine Instructions DMS English 07/2024 PDF No
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists DMS English 04/2022 PDF No
F-01673 Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists DMS English 04/2022 Word No
F-01673A Prior Authorization/Preferred Drug List (PA/PDL) for Orexin Receptor Antagonists, Instructions DMS English 04/2022 PDF No
F-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-11078 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets DMS English 07/2022 Word No
F-11078A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules, Suspensions, and Non-Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF 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 DMS English 07/2022 Word No
F-00433A Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-00315C Prior Notice and Consent for Evaluation and Assessment DMS English 03/2017 Word No
F-00315C Prior Notice and Consent for Evaluation and Assessment DMS English 03/2017 PDF No
F-00315C Prior Notice and Consent for Evaluation and Assessment, Spanish DMS Spanish 03/2017 PDF No
F-11252 Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum DMS English 05/2019 Word No

Glossary

 
Last revised August 26, 2024