• General Information
  • Introduction
  • Provider Certification
  • Eligibility Criteria
  • Applications
    • Introduction
    • Obtaining Forms
  • Eligibility Verification
  • Duration of Benefits
    • Introduction
    • Extensions
  • Applying for Full-Benefit Medicaid
  • Covered Services
  • Claims
• Appendix
  • Appendix 1 — Instructions for Completing the Presumptive Eligibility for Pregnant Women Application
  • Appendix 2 — Sample Presumptive Eligibility for Pregnant Women Application
• PDF

General Information

Applications

Obtaining Forms

Providers may submit an electronic request for the form by completing an electronic order form (DMT 25A). The DMT 25A and instructions for ordering forms electronically are available from the Department of Health and Family Services (DHFS) Web site at dhs.wisconsin.gov/forms/PrintFormsOnline.htm.

Providers may also submit requests by fax to (608) 266-1096 or by mail to the following address:

Forms/Publications Manager
Division of Health Care Financing
PO Box 309
Madison WI 53701-0309

When requesting the form, providers should indicate the form name, form number, and the quantity needed.

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