Wisconsin Department of Health Services Forms

This Form is used for scheduling and documenting the 12-month visit at a general pediatric clinic in Wisconsin.

This form is used for requesting special handling of pharmaceuticals in Wisconsin.

This Form is used for conducting a functional assessment for mental health day treatment in Wisconsin. It helps evaluate an individual's functional abilities and needs for treatment.

This Form is used for employers in Wisconsin to verify their employees' earnings. It is important for employers to accurately report the earnings of their employees for tax and benefit purposes. This form helps ensure that the information provided is correct and reliable.

Print out this Wisconsin-specific will to pre-organize your health care in a potential scenario, prevent major arguments between your family members, control any necessary medical treatments and procedures and reduce potential extra medical bills.

This form is used for applying for Foodshare benefits in the state of Wisconsin.

This document is an application packet for BadgerCare Plus, a healthcare program in Wisconsin.

This Form is used for applying for Wisconsin Medicaid benefits for the elderly, blind or disabled individuals. This document contains the application packet required for submitting an application.

This document provides guidance and information for completing the Collaborative Systems of Care (Csoc) Quarterly Reporting for Wisconsin.

This form is used for requesting a review of the maximum allowed cost for specialty drugs in the state of Wisconsin.

This form is used for reporting instances of misconduct in the state of Wisconsin.

This form is used for the Foodshare Wisconsin Repayment Agreement in the state of Wisconsin. It outlines the terms and conditions for individuals to repay any overpayments or misspent benefits received through the Foodshare program.

This form is used for applying for the Badger Bounce Back program in the state of Wisconsin.

This form is used for obtaining approval for Comprehensive Community Services (CCS) or Non-traditional Services in the state of Wisconsin.

This document provides instructions for completing Form F-11066, which is a Prior Authorization/Oxygen Attachment form required in the state of Wisconsin. It is used to request approval for oxygen therapy services.

This Form is used for requesting prior authorization for otological medical procedures in the state of Wisconsin. It includes a physician report on the patient's condition and treatment plan.

This form is used for designating a prescriber for restricted medication services in the Pharmacy Services Lock-In Program in Wisconsin.

This Form is used for HMO members in Wisconsin to request a referral for pharmacy services under the Pharmacy Services Lock-In Program.

This document is a cover page that needs to be attached to a specific claim form for the state of Wisconsin. It provides instructions for submitting the claim form.

This form is used for designating an alternate prescriber for restricted medication services in the Pharmacy Services Lock-In Program in Wisconsin.

This Form is used for providing prior authorization and attaching psychotherapy information in the state of Wisconsin.

This Form is used for submitting prior authorization and care plan attachments in the state of Wisconsin. It provides instructions on how to complete the form and what information is required.

This document is used to provide instructions for completing the Form F-11035 Prior Authorization Dental Request Form (Pa/Drf) in the state of Wisconsin.

This document is used for submitting an amendment request for prior authorization in Wisconsin. It provides instructions on how to complete the form and what information is required.

This Form is used for submitting prior authorization for blood glucose meters and test strips in Wisconsin.

This type of document is used for submitting encounters from rural health clinics to Medicaid HMOs in Wisconsin.

This Form is used for recording information about specialized medical vehicle transportation trips and verifying medical care in Wisconsin. It provides instructions for filling out Form F-01050.

This form is used for applying for a radioactive material license for medical use in the state of Wisconsin. It is required for facilities or individuals who want to use radioactive materials for medical purposes.

This Form is used for training, experience, and preceptor attestation for individuals seeking to become a Radiation Safety Officer for Medical Use in Wisconsin.

This form is used for training, experience, and preceptor attestation for authorized users in Wisconsin. It is specifically for those who do not require a written directive.

This Form is used for training, experience and preceptor attestation for handling unsealed radioactive material in Wisconsin that requires a written directive.

This form is used for recording the cumulative occupational exposure history of individuals in the state of Wisconsin. It helps track and monitor the exposure to various hazards in the workplace over time.