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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 Available to order
F-11285 HealthCheck Screener Affirmation (PDF) OIG English 04/2022 No
F-11285 HealthCheck Screener Affirmation (Word) OIG English 04/2022 No
F-01067 HealthCheck Your Child's Speech and Hearing (PDF) DMS English 07/2008 No
F-01067 HealthCheck Your Child's Speech and Hearing (Word) DMS English 07/2008 No
F-13148 HIPAA Privacy Access Request (PDF) DMS English 07/2008 No
F-13149 HIPAA Privacy Accounting Request (PDF) DMS English 07/2008 No
F-13151 HIPAA Privacy Amendment Request (PDF) DMS English 07/2008 No
F-13145 HIPAA Privacy Authorization for Use or Disclosure (PDF) DMS English 07/2008 No
F-13146 HIPAA Privacy Revocation of Authorization (PDF) DMS English 07/2008 No
F-01359 Historical Earnings Verification Request (Word) DMS English 02/2022 No
F-03112 HMO Quarterly Appeals Log (Excel) DMS English 02/2025 No
F-03112A HMO Quarterly Grievance Log (Excel) DMS English 02/2025 No
F-03112AI HMO Quarterly Grievance Log Instructions (PDF) DMS English 01/2024 No
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program (PDF) DMS English 06/2023 No
F-02319H Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program, Hmong (PDF) DMS Hmong 06/2023 No
F-02319S Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program, Spanish (PDF) DMS Spanish 06/2023 No
F-22541 Incident Report - IRIS (PDF) DMS English 07/2020 No
F-22541 Incident Report - IRIS (Word) DMS English 07/2020 No
F-20445 Individual Service Plan - Children’s Long-Term Support Programs (PDF) DMS English 09/2022 No
F-20445 Individual Service Plan - Children’s Long-Term Support Programs (Word) DMS English 09/2022 No
F-20445H Individual Service Plan - Children’s Long-Term Support Programs, Hmong (PDF) DMS Hmong 09/2022 No
F-20445H Individual Service Plan - Children’s Long-Term Support Programs, Hmong (Word) DMS Hmong 09/2022 No
F-20445I Individual Service Plan - Children’s Long-Term Support Programs, Instructions (PDF) DMS English 09/2022 No
F-20445S Individual Service Plan - Children’s Long-Term Support Programs, Spanish (PDF) DMS Spanish 09/2022 No
F-20445S Individual Service Plan - Children’s Long-Term Support Programs, Spanish (Word) DMS Spanish 09/2022 No
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs (Word) DMS English 05/2022 No
F-20445A Individual Service Plan: Outcomes, Children’s Long-Term Support Programs (PDF) DMS English 05/2022 No
F-20445AH Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Hmong (PDF) DMS Hmong 05/2022 No
F-20445AH Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Hmong (Word) DMS Hmong 05/2022 No
F-20445AS Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Spanish (PDF) DMS Spanish 05/2022 No
F-20445AS Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Spanish (Word) DMS Spanish 05/2022 No
F-10097 Institutional Medicaid Income Allocation (PDF) DMS English 04/2024 No
F-10097H Institutional Medicaid Income Allocation, Hmong (PDF) DMS Hmong 04/2024 No
F-10097S Institutional Medicaid Income Allocation, Spanish (PDF) DMS Spanish 04/2024 No
F-03112I Instructions for Logging HMO Appeals (PDF) DMS English 02/2025 No
F-00107A Instructions, Self-Employment Income Report (PDF) DMS English 04/2026 No
F-00107ACM Instructions, Self-Employment Income Report, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 04/2026 No
F-00107AH Instructions, Self-Employment Income Report, Hmong (PDF) DMS Hmong 04/2026 No
F-00107AS Instructions, Self-Employment Income Report, Spanish (PDF) DMS Spanish 04/2026 No
F-01234A Instructions: Explanation of Medical Benefits (PDF) DMS English 04/2026 No
F-11010A Instructions: Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format (PDF) DMS English 01/2018 No
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF) DMS English 07/2008 No
F-03102 Katie Beckett Disability Evaluation Form (PDF) DMS English 11/2022 No
F-03102 Katie Beckett Disability Evaluation Form (Word) DMS English 11/2022 No
F-01661A Letter - Foster Care Termination, Youth (Word) DMS English 11/2023 No
F-01567A Letter: Request for Assignment of Medical Benefits (Word) DMS English 01/2021 No
F-03240 Long-Term Care (LTC) Waiver Community Transportation Attestation (Word) DMS English 04/2026 No
F-03240 Long-Term Care (LTC) Waiver Community Transportation Attestation (PDF) DMS English 04/2026 No
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation (Word) DMS English 09/2024 No
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation (PDF) DMS English 09/2024 No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised September 30, 2025