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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-16001SO Notice of Denial of Benefits/Negative Change in Benefits, Somali (PDF) DMS Somali 05/2018 No
F-16001S Notice of Denial of Benefits/Negative Change in Benefits, Spanish (Word) DMS Spanish 05/2018 No
F-16014 Notice of Program Violation (PDF) DMS English 03/2018 No
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF) DMS English 07/2008 No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request (PDF) DMS English 11/2018 No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request (Word) DMS English 11/2018 No
F-01013A Nurse Aide Training and Competency Test Reimbursement Request Instructions (PDF) DMS English 03/2019 No
F-01020 Nursing Home Care Determination Request (PDF) DMS English 07/2018 No
F-01020 Nursing Home Care Determination Request (Word) DMS English 07/2018 No
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (PDF) DMS English 10/2008 No
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (Word) DMS English 10/2008 No
F-11103A Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan: Completion Instructions (PDF) DMS English 07/2012 No
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services (PDF) DMS English 07/2008 No
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services (Word) DMS English 07/2008 No
F-01199 Optional School-Based Services Activity Medication Administration (PDF) DMS English 07/2008 No
F-01199 Optional School-Based Services Activity Medication Administration (Word) DMS English 07/2008 No
F-11271 Personal Care Provider Addendum (PDF) DMS English 09/2019 No
F-11271 Personal Care Provider Addendum (Word) DMS English 09/2019 No
F-11133 Personal Care Screening Tool (PCST) (Word) DMS English 11/2024 No
F-11133 Personal Care Screening Tool (PCST) (PDF) DMS English 11/2024 No
F-11133A Personal Care Screening Tool (PCST) Instructions (PDF) DMS English 11/2024 No
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding (PDF) DMS English 03/2017 No
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member (PDF) DMS English 02/2025 No
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member (Word) DMS English 02/2025 No
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program (PDF) DMS English 02/2025 No
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program (Word) DMS English 02/2025 No
F-00842 Pharmacy Services Lock-In Program - Program Summary (PDF) DMS English 07/2013 No
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services (PDF) DMS English 02/2025 No
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services (Word) DMS English 02/2025 No
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services (PDF) DMS English 02/2025 No
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services (Word) DMS English 02/2025 No
F-00406 Pharmacy Services Lock-In Program HMO Member Designation of Pharmacy (Word) DMS English 02/2025 No
F-00406 Pharmacy Services Lock-In Program HMO Member Designation of Pharmacy (PDF) DMS English 02/2025 No
F-11184 Pharmacy Services Lock-In Program Member Designation of Providers (Word) DMS English 02/2025 No
F-11184 Pharmacy Services Lock-In Program Member Designation of Providers (PDF) DMS English 02/2025 No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use (Word) DMS English 02/2025 No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use (PDF) DMS English 02/2025 No
F-13074 Pharmacy Special Handling Request (Word) DMS English 04/2014 No
F-13074 Pharmacy Special Handling Request (PDF) DMS English 04/2014 No
F-13074A Pharmacy Special Handling Request: Completion Instructions (PDF) DMS English 07/2012 No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request (Word) DMS English 01/2021 No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request (PDF) DMS English 01/2021 No
F-00401A Preferred Drug List (PDL) Expedited Emergency Supply Request, Instructions (PDF) DMS English 01/2021 No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist (PDF) DMS English 06/2023 No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist (Word) DMS English 06/2023 No
F-03183 Prenatal Care Coordination Care Plan (PDF) DMS English 06/2023 No
F-03183 Prenatal Care Coordination Care Plan (Word) DMS English 06/2023 No
F-03183A Prenatal Care Coordination Care Plan, Instructions (PDF) DMS English 06/2023 No
F-03186 Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring (PDF) DMS English 12/2023 No
F-03186 Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring (Word) DMS English 12/2023 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