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ForwardHealth Forms

ForwardHealth Forms

The forms listed below can be viewed with Adobe Acrobat Reader® or Microsoft Word®.

Form Name Form Number PDF Format Word Format
Abortion Certification Statements F-1161 PDF (94 KB) Word (65 KB)
Acknowledgment of Receipt of Hysterectomy Information, 06/13
Completion Instructions
Hmong, 06/13
Completion Instructions
Spanish, 06/13
Completion Instructions
F-01160
F-01160A
F-01160H
F-01160AH
F-01160S
F-01160AS
PDF (1 MB)
PDF (24 KB)
PDF (523 KB)
PDF (29 KB)
PDF (42 KB)
PDF (1 MB)
Word (59 KB)

Word (60 KB)
 
Word (72 KB)
Adjustment/Reconsideration Request, 07/12
Completion Instructions
F-13046
F-13046A
PDF (100 KB)
PDF (108 KB)
Word (73 KB)
Agency Application for Access to Web-Based Personal Care Screening Tool, 04/10 F-20418 PDF (17 KB) Word (55 KB)
Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections, 04/14
Completion Instructions
F-00286
F-00286A
PDF (1149 KB)
PDF (30 KB)
Word (37 KB)
Breast and Cervical Cancer Screening Activity Report (ARF), 10/08
Completion Instructions, 10/11
F-44723
F-44723I
PDF (101 KB)
PDF (80 KB)
Word (124 KB)
Breast Cancer Diagnostic and Follow-Up Report (DRF), 10/11
Completion Instructions
F-44724
F-44724I
PDF (106 KB)
PDF (86 KB)
Word (114 KB)
Breast Pump Order, 02/09 F-01153 PDF (78 KB)  
Case Management Agency Self-Audit Checklist, 02/09 F-00023 PDF (143 KB)  
Certification Criteria For Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus F-11318 PDF (94 KB)  
Certification Criteria For Providers Express Enrollment of Pregnant Women in BadgerCare Plus F-11317 PDF (93 KB)  
Certification of Emergency for Non-U.S. Citizens, 02/09
Completion Instructions
F-01162
F-01162A
PDF (44 KB)
PDF (62 KB)
 
Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Recipients under Age 21, 02/09 F-11047 PDF (34 KB)  
Certification of Need for Emergency Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Recipients under Age 21 and in cases of Medicaid Determination after Admission, 02/09 F-11048 PDF (30 KB)  
Certification of Need for Specialized Medical Vehicle Transportation, 06/09
Completion Instructions
F-01197
F-01197A
PDF (75 KB)
PDF (61 KB)
Word (43 KB)
Certification of Public Expenditures, 07/08 F-1003 PDF (108 KB)  
Cervical Cancer Diagnostic and Follow-Up Report (DRF), 10/11
Completion Instructions
F-44729
F-44729I
PDF (106 KB)
PDF (104 KB)
Word (111 KB)
Child Care Coordination Family Questionnaire, 02/09
Completion Instructions
F-01118
F-01118A
PDF (414 KB)
PDF (52 KB)
 
Claim Form Attachment Cover Page
Completion Instructions
F-13470
F-13470A
PDF (93 KB)
PDF (64 KB)
Word (48 KB)
Claim Refund, 08/12
Completion Instructions
F-13066
F-13066A
PDF (69 KB)
PDF (32 KB)
Word (59 KB)
Comprehensive Community Services Program, 07/14 F-01270 PDF (560 KB)
Word (23 KB)
Consent for Sterilization
Completion Instructions
Spanish
F-01164
F-01164A
F-01164S
PDF (146 KB)
PDF (56 KB)
PDF (1 MB)
Word (49 KB)
 
Word (72 KB)
Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics, 04/09
Completion Instructions, 04/14
F-11079
F-11079A
Excel (23 KB)
PDF (36 KB)
 
Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds), 04/09
Completion Instructions, 04/14
F-11080
F-11080A
Excel (48 KB)
PDF (35 KB)
 
Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds), 04/09
Completion Instructions, 04/14
F-11080CP
F-11080CA
Excel (69 KB)
PDF (35 KB)
 
Declaration of Supervision for Nonbilling Providers, 07/12 F-01182 PDF (50 KB) Word (50 KB)
Election of Hospice Benefit for Members 20 and Under, 12/10
    Hmong, 12/10
    Spanish, 12/10
F-1009A
F-1009AH
F-1009AS
PDF (24 KB)
PDF (25 KB)
PDF (25 KB)
Word (36 KB)
Word (25 KB)
Word (25 KB)
Election of Hospice Benefit for Members 21 and Older, 12/10
    Hmong, 12/10
    Spanish, 12/10
F-1009B
F-1009BH
F-1009BS
PDF (23 KB)
PDF (25 KB)
PDF (25 KB)
Word (35 KB)
Word (25 KB)
Word (25 KB)
Estate Recovery Program Notification of Death, 02/09 F-13175 PDF (29 KB)  
Explanation of Medicare Benefits for Diabetic Supply Claims form, 10/13 F-00898
F-00898A
PDF (1341 KB)
PDF (35 KB)
Word (35 KB)
Federally Qualified Health Center Cost Report Forms, 04/09
Completion Instructions, 04/14
F-11129B-H
F-11129A
Excel (133 KB)
PDF (102 KB)
 
Federally Qualified Health Center Interim Report, 04/09
Completion Instructions, 04/14
F-11130
F-11130A
Excel (21 KB)
PDF (47 KB)
 
HealthCheck Forms
HealthCheck Adolescent Review, 07/08
Spanish, 07/08
F-01062
F-01062S
PDF (129 KB)
PDF (131 KB)
Word (64 KB)
Word (74 KB)
HealthCheck Age Specific Documentation, 01/11:
Confidential Health Survey
Spanish
General Pediatric Clinic — 3 to 4 Week Visit
General Pediatric Clinic — 6-8 Week Visit
General Pediatric Clinic — 4 Month Visit
General Pediatric Clinic — 6 Month Visit
General Pediatric Clinic — 9 Month Visit
General Pediatric Clinic — 12 Month Visit
General Pediatric Clinic — 15 Month Visit
General Pediatric Clinic — 18 Month Visit
General Pediatric Clinic — 24 Month Visit
General Pediatric Clinic — Pre-school School Visit
General Pediatric Clinic — Elementary School Visit
General Pediatric Clinic — Teenager Visit
 
F-01068M
F-01068MS
F-01068A
F-01068B
F-01068C
F-01068D
F-01068E
F-01068F
F-01068G
F-01068H
F-01068I
F-01068J
F-01068K
F-01068L
 
PDF (189 KB)
PDF (134 KB)
PDF (195 KB)
PDF (137 KB)
PDF (87 KB)
PDF (193 KB)
PDF (152 KB)
PDF (169 KB)
PDF (160 KB)
PDF (172 KB)
PDF (236 KB)
PDF (160 KB)
PDF (149 KB)
PDF (134 KB)
 
Word (72 KB)
Word (92 KB)
Word (141 KB)
Word (149 KB)
Word (152 KB)
Word (171 KB)
Word (147 KB)
Word (178 KB)
Word (152 KB)
Word (169 KB)
Word (189 KB)
Word (144 KB)
Word (134 KB)
Word (157 KB)
HealthCheck Family History, 07/08
Spanish, 07/08
F-01063
F-01063S
PDF (392 KB)
PDF (391 KB)
Word (124 KB)
Word (138 KB)
HealthCheck Food Records, 07/08:
Adolescent / 13 to 20 Years of Age
Spanish
Child / 1 to 12 Years of Age
Spanish
Infant / Birth to 12 Months of Age
Spanish
 
F-01066B
F-01066BS
F-01066A
F-01066AS
F-01066
F-01066S
 
PDF (77 KB)
PDF (77 KB)
PDF (72 KB)
PDF (62 KB)
PDF (68 KB)
PDF (64 KB)
 
Word (53 KB)
Word (47 KB)
Word (55 KB)
Word (57 KB)
Word (58 KB)
Word (65 KB)
HealthCheck Individual Health History, 10/08
Hmong
Spanish
F-01002
F-01002H
F-01002S
PDF (797 KB)
PDF (861 KB)
PDF (618 KB)
Word (419 KB)
Word (437 KB)
Word (473 KB)
HealthCheck Your Child's Speech and Hearing, 07/08
F-01067
PDF (280 KB)
Word (120 KB)
HealthCheck Referral, 02/09 F-00021 PDF (16 KB)  
Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge F-01010 PDF (112 KB) Word (37 KB)
Discontinued. See enrollment requirements . In-State Emergency Provider Data Sheet, 07/12
Completion Instructions
F-11002
F-11002A
   
Managed Care Program Provider Appeal, 03/09 F-12022 PDF (87 KB) Word (43 KB)
Mental Health Day Treatment Functional Assessment, 10/08
Completion Instructions, 07/12
F-11090
F-11090A
PDF (174 KB)
PDF (95 KB)
Word (272 KB)
Newborn Report, 06/11 F-1165 PDF (75 KB) Word (79 KB)
Notification of Hospice Benefit Election F-1008 PDF (91 KB) Word (75 KB)
Nurse Aide Training and Competency Test Reimbursement Request, 07/12
Completion Instructions
F-01013
F-01013A
PDF (81 KB)
PDF (79 KB)
Word (58 KB)
Nursing Home Rate Administrative Review Request, 02/09
Completion Instructions
F-00022
F-00022A
PDF (12 KB)
PDF (17 KB)
 
Other Coverage Discrepancy Report, 09/12 F-01159 PDF (73 KB) Word (101 KB)
Optional School-Based Services Activity Medication Administration, 07/08 F-1199 PDF (65 KB) Word (73 KB)
Optional School-Based Services Activity Log Nursing / Therapy Medical Services, 07/08 F-1198 PDF (69 KB) Word (61 KB)
Discontinued. See enrollment requirements . Out-of-State Provider Data Sheet, 07/12
Completion Instructions
F-11001
F-11001A
   
Outpatient Mental Health Assessment and Treatment/Recovery Plan, 10/08
Completion Instructions, 07/12
F-11103
F-11103A
PDF (112 KB)
PDF (104 KB)
Word (235 KB)
Personal Care Addendum, 10/08
Completion Instructions, 07/12
F-11136
F-11136A
PDF (114 KB)
PDF (87 KB)
Word (168 KB)
Personal Care Prior Authorization Provider Acknowledgement, 07/12 F-11134 PDF (83 KB) Word (97 KB)
Personal Care Screening Tool (PCST), 01/11
Completion Instructions, 07/12
F-11133
F-11133A
PDF (147 KB)
PDF (179 KB)
Word (235 KB)
Pharmacy Related Forms
Adjustment/Reconsideration Request
Completion Instructions
F-13046
F-13046A
PDF (100 KB)
PDF (108 KB)
Word (73 KB)
Drug Claims — Compound Drug Claim, 07/12
Completion Instructions
F-13073
F-13073A
PDF (83 KB)
PDF (101 KB)
Word (159 KB)
Drug Claims — Noncompound Drug Claim, 10/12
Completion Instructions
F-13072
F-13072A
PDF (100 KB)
PDF (97 KB)
Word (41 KB)
Drug Addition Review Request, 04/14
F-00020 PDF (653 KB) Word (49 KB)
Expedited Emergency Supply Request, 10/11
Completion Instructions, 07/12
F-00401
F-00401A
PDF (153 KB)
PDF (125 KB)
Word (58 KB)
Pharmacy Special Handling Request, 04/14
Completion Instructions
F-13074
F-13074A
PDF (506 KB)
PDF (32 KB)
Word (56 KB)
Prior Authorization Amendment Request, 07/12
Completion Instructions
F-11042
F-11042A
PDF (61 KB)
PDF (83 KB)
Word (67 KB)
Prior Authorization/Brand Medically Necessary Attachment (PA/BMNA), 01/15
Completion Instructions
F-11083
F-11083A
PDF (592 KB)
PDF (54 KB)
Word (65 KB)
Prior Authorization/Drug Attachment (PA/DGA), 10/13
Completion Instructions
F-11049
F-11049A
PDF (1 MB)
PDF (34 KB)
Word (115 KB)
Prior Authorization Drug Attachment For Anti-Obesity Drugs, 01/15
Completion Instructions
F-00163
F-00163A
PDF (631 KB)
PDF (70 KB)
Word (63 KB)
Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger, 03/14
Completion Instructions
F-00556
F-00556A
PDF (68 KB)
PDF (20 KB)
Word (97 KB)
Prior Authorization Drug Attachment for Blood Glucose Meters and Test Strips, 01/14
Completion Instructions
F-00239
F-00239A
PDF (68 KB)
PDF (20 KB)
Word (97 KB)
Prior Authorization Drug Attachment for Hepatitis C Agents, 12/14
Completion Instructions
F-01247
F-01247A
PDF (589 KB)
PDF (58 KB)
Word (50 KB)
Prior Authorization Drug Attachment for Hepatitis C Agents Renewal, 12/14
Completion Instructions
F-01248
F-01248A
PDF (568 KB)
PDF (40 KB)
Word (45 KB)
Prior Authorization Drug Attachment for Hepatitis C Protease Inhibitors, 7/14
Completion Instructions
F-00583
F-00583A
PDF (586 KB)
PDF (39 KB)
Word (72 KB)
Prior Authorization Drug Attachment for Lipotropics, Omega-3 Acids, 07/13
Completion Instructions, 10/13
F-00162
F-00162A
PDF (69 KB)
PDF (42 KB)
Word (98 KB)
Prior Authorization Drug Attachment for Modafinil ® and Nuvigil ® , 01/15
Completion Instructions
F-00079
F-00079A
PDF (628 KB)
PDF (23 KB)
Word (71 KB)
Prior Authorization Drug Attachment for Stribild, 07/14
Completion Instructions
F-01249
F-01249A
PDF (541 KB)
PDF (23 KB)
Word (49 KB)
Prior Authorization Drug Attachment for Synagis ® , 10/14
Completion Instructions
F-00142
F-00142A
PDF (2939 KB)
PDF (49 KB)
Word (85 KB)
Prior Authorization Drug Attachment for Xyrem, 01/15
Completion Instructions
F-01430
F-01430A
PDF (614 KB)
PDF (53 KB)
Word (53 KB)
Prior Authorization Fax Cover Sheet, 12/11
F-01176 PDF (16 KB) Word (37 KB)
Prior Authorization/Preferred Drug List (PA/PDL) Exemption Request, 09/13
Completion Instructions
F-11075
F-11075A
PDF (99 KB)
PDF (90 KB)
Word (113 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids, 07/13
Completion Instructions
F-00194
F-00194A
PDF (21 KB)
PDF (107 KB)
Word (115 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis, 12/12
Completion Instructions
F-11304
F-11304A
PDF (83 KB)
PDF (27 KB)
Word (101 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease, 12/12
Completion Instructions
F-11305
F-11305A
PDF (71 KB)
PDF (24 KB)
Word (101 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis, 01/14
Completion Instructions
F-11306
F-11306A
PDF (66 KB)
PDF (24 KB)
Word (101 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Psoriatic Arthritis, 12/12
Completion Instructions
F-11307
F-11307A
PDF (75 KB)
PDF (24 KB)
Word (105 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule(CAM) Antagonist Drugs for Rheumatoid Arthritis (RA) and Polyarticular Juvenile RA, 12/12
Completion Instructions
F-11308
F-11308A
PDF (74 KB)
PDF (25 KB)
Word (109 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis, 01/14
Completion Instructions
F-00694
F-00694A
PDF (74 KB)
PDF (25 KB)
Word (109 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Fentanyl Mucosal Agents, 07/13
Completion Instructions
F-00281
F-00281A
PDF (48 KB)
PDF (22 KB)
Word (107 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Glucagon-Like Peptide (GLP-1) Agents, 10/14
Completion Instructions
F-00238
F-00238A
PDF (138 KB)
PDF (88 KB)
Word (143 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs, 10/14
Completion Instructions
F-11092
F-11092A
PDF (631 KB)
PDF (73 KB)
  Word (150 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Other, 07/13
Completion Instructions, 07/12
F-00280
F-00280A
PDF (50 KB)
PDF (22 KB)
  Word (108 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Migraine Agents, Injectable, 06/12
Completion Instructions
F-00622
F-00622A
PDF (50 KB)
PDF (22 KB)
  Word (108 KB)
Prior Authorization / Preferred Drug List (PA/PDL) For Multiple Sclerosis (MS) Agents, Immunomodulators, 10/14
Completion Instructions
F-00805
F-00805A
PDF (49 KB)
PDF (46 KB)
  Word (49 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors, 12/12
Completion Instructions
F-11077
F-11077A
PDF (53 KB)
PDF (90 KB)
Word (132 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Capsules and Tablets, 10/11
Completion Instructions, 07/12
F-11078
F-11078A
PDF (48 KB)
PDF (26 KB)
  Word (138 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets, 07/13
Completion Instructions
F-00433
F-00433A
PDF (48 KB)
PDF (26 KB)
  Word (138 KB)
Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents, 12/12
Completion Instructions
F-11097
F-11097A
PDF (118 KB)
PDF (29 KB)
Word (123 KB)
Prior Authorization / Preferred Drug List (PA/PDL) For Opioid Dependency Agents, 07/14
Completion Instructions, 07/14
F-00081
F-00081A
PDF (1,376 KB)
PDF (34 KB)
Word (66 KB)
Prior Authorization/Preferred Drug List (PA/PDL) for Symlin, 10/11
Completion Instructions, 07/12
F-00080
F-00080A
PDF (143 KB)
PDF (19 KB)
Word (165 KB)
Prior Authorization Request Form (PA/RF), 05/13
F-11018 PDF (80 KB) Word (94 KB)
STAT-PA System Instructions, 10/11
F-11055 PDF (93 KB)  
State Maximum Allowed Cost Drug Pricing Review Request, 10/13
Completion Instructions
F-00030
F-00030A
PDF (1 MB)
PDF (33 KB)
Word (67 KB)
Pharmacy Services Lock-In Forms
Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medications Services, 12/10 (HMO Only)
F-00345 PDF (20 KB) Word (46 KB)
Pharmacy Services Lock-In Program HMO Referral for Pharmacy Services Lock-In of HMO Member, 07/13 (HMO Only)
F-00841 PDF (1.30 MB) Word (27 KB)
Pharmacy Services Lock-In Program HMO Responsibilities For Member Referral To Pharmacy Services Lock-In Program, 07/13 (HMO Only)
F-00840 PDF (91 KB) Word (60 KB)
Pharmacy Services Lock-In Program Summary, 07/13 (HMO Only)
F-00842 PDF (91 KB)  
Pharmacy Services Lock-In Program Designation of Alternate Prescriber for Restricted Medications Services, 12/10 (Provider and HMO)
F-11183 PDF (17 KB) Word (43 KB)
Pharmacy Services Lock-In Program Request for Review Of Member Prescription Drug Use, 05/10 (Provider and HMO)
F-00250 PDF (28 KB) Word (45 KB)
Physician Certification / Recertification of Terminal Illness F-01011 PDF (111 KB) Word (38 KB)
Pre-admission Screen and Resident Review (PASAAR) Level 1 Screen, 08/08 F-22191 PDF (28 KB) Word (154 KB)
Pre-Natal Care Coordination Program Pregnancy Questionnaire, 02/09
Completion Instructions
Hmong (02/09) — F-01105H (30 KB)
Spanish (02/09) — F-01105S (31 KB)
F-01105
F-01105A

PDF (199 KB)
PDF (70 KB)

 


Prior Authorization/Adult Mental Health Day Treatment Attachment (PA/AMHDTA), 07/12
Completion Instructions
F-11038
F-11038A
PDF (109 KB)
PDF (104 KB)
Word (122 KB)
Prior Authorization / Birth to 3 Attachment (PA/B3), 07/12 F-11011 PDF (71 KB) Word (98 KB)
Prior Authorization/Care Plan Attachment (PA/CPA), 03/10
Completion Instructions, 07/12
F-11096
F-11096A
PDF (68 KB)
PDF (37 KB)
Word (131 KB)
Prior Authorization/Child/Adolescent Day Treatment Attachment (PA/CADTA), 07/12
Completion Instructions
F-11040
F-11040A
PDF (137 KB)
PDF (150 KB)
Word (143 KB)
Prior Authorization/Chiropractic Attachment (PA/CA), 07/12
Completion Instructions
F-11029
F-11029A
PDF (88 KB)
PDF (104 KB)
Word (108 KB)
Prior Authorization/Dental Attachment 1 (PA/DA1), 10/08
Completion Instructions, 07/12
F-11010
F-11010A
PDF (96 KB)
PDF (83 KB)
Word (124 KB)
Prior Authorization/Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services, 07/12 F-11014 PDF (307 KB) Word (106 KB)
Prior Authorization Dental Request Form, 07/12
Completion Instructions
F-11035
F-11035A
PDF (234 KB)
PDF (110 KB)
Word
Prior Authorization Drug Attachment for Onabotulinumtoxina (Botox ® ) to Treat Chronic Migraines, 08/13
Completion Instructions
F-00701
F-00701A
PDF (104 KB)
PDF (18 KB)
Word (112 KB)
Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA), 07/12
Completion Instructions
F-11030
F-11030A
PDF (79 KB)
PDF (78 KB)
Word (98 KB)
Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA), 10/12
Completion Instructions
F-11054
F-11054A
PDF (90 KB)
PDF (93 KB)
Word (108 KB)
Prior Authorization / Environmental Lead Inspection form, 10/08
Completion Instructions, 07/12
F-11062
F-11062A
PDF (97 KB)
PDF (89 KB)
Word (100 KB)
Prior Authorization/Health and Behavior Intervention Attachment (PA/HBA), 07/12
Completion Instructions
F-11088
F-11088A
PDF (67 KB)
PDF (87 KB)
Word (94 KB)
Prior Authorization/Home Health Therapy Attachment (PA/HHTA), 07/12
Completion Instructions
F-11044
F-11044A
PDF (79 KB)
PDF (107 KB)
Word (96 KB)
Prior Authorization/In-Home Treatment Attachment (PA/ITA), 07/12
Completion Instructions
F-11036
F-11036A
PDF (98 KB)
PDF (132 KB)
Word (141 KB)
Prior Authorization Intensive In-Home Mental Health/Substance Abuse Services Assessment And Recovery/Treatment Plan Attachment, 02/10
Completion Instructions, 07/12

F-00212
F-00212A

PDF (151 KB)
PDF (150 KB)
Word (92 KB)
Prior Authorization/"J" Code Attachment (PA/JCA), 07/12
Completion Instructions
F-11034
F-11034A
PDF (81 KB)
PDF (90 KB)
Word (94 KB)
Prior Authorization/Mental Health and/or Substance Abuse Evaluation Attachment (PA/EA), 07/12
Completion Instructions
F-11033
F-11033A
PDF (72 KB)
PDF (107 KB)
Word (92 KB)
Prior Authorization/Oxygen Attachment (PA/OA), 07/12
Completion Instructions
F-11066
F-11066A
PDF (92 KB)
PDF (90 KB)
Word (125 KB)
Prior Authorization/Physician Attachment (PA/PA), 07/12
Completion Instructions
F-11016
F-11016A
PDF (76 KB)
PDF (70 KB)
Word (97 KB)
Prior Authorization/Physician Otological Report (PA/POR), 07/12
Completion Instructions
F-11019
F-11019A
PDF (70 KB)
PDF (86 KB)
Word (97 KB)
Prior Authorization/Psychotherapy Attachment (PA/PSYA), 07/12
Completion Instructions
F-11031
F-11031A
PDF (87 KB)
PDF (110 KB)
Word (104 KB)
Prior Authorization Request Form (PA/RF), 05/13 F-11018 PDF (80 KB) Word (94 KB)
Prior Authorization Request Form (PA/RF) Completion Instructions for Residential Care Center Treatment Services, 07/12 F-11076 PDF (89 KB)  
Prior Authorization Requirements Exemption Request for Computed Tomography (CT) and Magnetic Resonance (MR) Imaging Services, 05/13 F-00787 PDF (89 KB) Word (89 KB)
Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC F-11076A PDF (97 KB) Word (97 KB)
Prior Authorization / Residential Care Center Treatment Services Attachment (PA/RCCA) for continuing services F-11076B PDF (78 KB) Word (97 KB)
Prior Authorization / Residential Care Center Treatment Attachment (PA/RCCA) Completion Instructions for initial admissions, unplanned readmissions, and for continuing services, 07/12 F-11076C PDF (84 KB)  
Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1), 05/13
Completion Instructions
F-11020
F-11020A
PDF (78 KB)
PDF (119 KB)
Word (84 KB)
Prior Authorization Request/Hearing Instrument and Audiological Services (PA/HIAS2), 07/12
Completion Instructions
F-11021
F-11021A
PDF (113 KB)
PDF (73 KB)
Word (147 KB)
Prior Authorization / Spell of Illness Attachment (PA/SOIA), 10/13
Completion Instructions
F-11039
F-11039A
PDF (131 KB)
PDF (452 KB)
Word (113 KB)
Prior Authorization/Substance Abuse Attachment (PA/SAA), 07/12
Completion Instructions
F-11032
F-11032A
PDF (125 KB)
PDF (125 KB)
Word (132 KB)
Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA), 07/12
Completion Instructions
F-11037
F-11037A
PDF (100 KB)
PDF (101 KB)
Word (131 KB)
Prior Authorization/Therapy Attachment (PA/TA), 07/12
Completion Instructions
F-11008
F-11008A
PDF (99 KB)
PDF (167 KB)
Word (118 KB)
Prior Authorization/Vision Services Attachment (PA/VA), 07/12
Completion Instructions
F-11051
F-11051A
PDF (90 KB)
PDF (89 KB)
Word (101 KB)
Private Duty Nursing For Members For Ventilator-Ddependent Life-Support Addendum, 08/12 F-11252 PDF (46 KB) Word (64 KB)
Private Duty Nursing Prior Authorization Acknowledgment F-11041 PDF (80 KB) Word (91 KB)
Probate Claims Notice, 07/08 F-13033 PDF (42 KB)  
Provider File Update Request, 12/13
Completion Instructions
F-00916
F-00916A
PDF (1444 KB)
PDF (28 KB)
Word (173 KB)
Provider Suggestion, 02/09 F-01016 PDF (56 KB)  
Record of Actual Daily Oxygen Use, 07/12
Completion Instructions
F-11067
F-11067A
PDF (65 KB)
PDF (70 KB)
Word (114 KB)
Reimbursement Request for a PASARR Level l Screen, 07/12
Completion Instructions
F-01012
F-01012A
PDF (82 KB)
PDF (79 KB)
Word (57 KB)
Request for Nursing Home Care Determination, 06/12
Completion Instructions
F-01020
F-01020A
PDF (29 KB)
PDF (26 KB)
Word (43 KB)
Request for Title XIX Care Level Determination, 10/06 F-62256 PDF (22 KB) Word (60 KB)
Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client / Residents, 10/06 F-62256A PDF (26 KB) Word (89 KB)
Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit F-1134 PDF (65 KB) Word (42 KB)
Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements, 07/12 F-01149 PDF (74 KB) Word (43 KB)
Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs, 04/09
Completion Instructions
F-11025
F-11025A
PDF (146 KB)
PDF (21 KB)
Word (150 KB)
Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs, 04/09
Completion Instructions, 04/14
F-11026
F-11026A
PDF (116 KB)
PDF (25 KB)
Word (134 KB)
Rural Health Clinic Provider Staff Encounters, 04/14 F-11081 Excel (34 KB)  
Rural Health Clinic Quarterly Cost Report, 04/09
Completion Instructions, 04/14
F-11027
F-11027A
Excel (13 KB)
PDF (32 KB)
 
Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses, 04/09
Completion Instructions, 04/14
F-11023
F-11023A
Excel (21 KB)
PDF (27 KB)
 
Rural Health Clinic Statistical Data, 07/12 F-11022 PDF (102 KB)  
Special Payment Rate Request for Ventilator- Dependent or Brain Injury Cases, 07/12 F-01168 PDF (109 KB) Word (38 KB)
Specialized Medical Vehicle Insurance Documentation Checklist, 03/14 F-00885 PDF (48 KB) Word (57 KB)
Specialized Medical Vehicle Providers Affidavit, 04/14 F-11237 PDF (49 KB) Word (69 KB)
Specialized Medical Vehicle Transportation Trip Ticket/Medical Care Verification (nonfillable), 07/08
Completion Instructions
F-1050
F-1050A
PDF (20 KB)
PDF (32 KB)
 
Sterilization Consent Form See "Consent for Sterilization."      
Timely Filing Appeals Request, 07/12 F-13047 PDF (63 KB) Word (70 KB)
Discontinued. See enrollment requirements . Urgent Care Dental In-State Emergency Provider Data Sheet, 07/12
Completion Instructions
F-11013
F-11013A
   
Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement, 07/08
Completion Instructions
F-1017
F-1017A
PDF (23 KB)
PDF (14 KB)
Word (40 KB)
Weekly Driver's Vehicle Inspection Report, 07/12
Completion Instructions
F-01302
F-01302A
PDF (125 KB)
PDF (7 KB)
 
Written Correspondence Inquiry, 07/12 F-01170 PDF (86 KB) Word (67 KB)
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Wisconsin Department of Health Services
   Production PROD_WIPortal_M470A_8-8