Medicaid Home

Apply For Benefits (ACCESS)

Applications

Check My Benefits

Contacts

Find a Provider

Publications

Report My Changes

Other Programs

HIPAA Privacy Notices

Applications and Forms

Adobe Acrobat Reader^® is needed to view PDF files.

Medicaid, BadgerCare and Family Planning Waiver Registration Application, F-10129 (PDF, 10 KB) — Use this form to start your application process and to set your application date.  You can also do this online at access.wi.gov.

• Hmong, F-10129H (PDF, 75 KB)

• Russian, F-10129R (PDF, 102 KB)

• Spanish, F-10129S (PDF, 74 KB)

Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review, F-10101  (PDF, 782 KB) — Use this form to apply.  You can also apply online at access.wi.gov.

• Hmong, F-10101H (PDF, 801 KB)
• Russian, F-10101R (PDF, 1.10 MB)
• Spanish, F-10101S (PDF, 790 KB)

Medicaid Disability Application, F-10112 (PDF, 263 KB) — Use this form to if you need a disability determination.

• Spanish, F-10112S (PDF, 790 KB)

Medicaid / FoodShare Wisconsin Authorization of Representative, F-10126 (PDF, 9 KB) — Designate someone to apply for Medicaid for you.

• Hmong, F-10126H (PDF, 57 KB)

• Spanish, F-10126S (PDF, 60 KB)

Medicaid Change Form, F-10137 (PDF, 75 KB) — To report changes.  You can also report changes online at access.wi.gov. 

• Hmong F-10137H (PDF, 14 KB), 

• Russian F-10137R (PDF, 80 KB), 

• Spanish F-10137S (PDF, 14 KB)

Medicaid Health Insurance Information, F-10115 (PDF, 249 KB)

Request For Fair Hearing, DHA-28 (PDF, 50 KB) — To request a Fair Hearing.

Fair Hearing Voluntary Withdrawal, DHA-17 (PDF_ — To withdraw your Fair Hearing request.

BadgerCare Plus Application Packet, F- 101082 (725 KB) —

• Hmong, F- 10182H (PDF, 201 KB)
• Spanish, F- 10182S (PDF, 752 KB)

Wisconsin Circuit Courts Transfer by Affidavit ($50,000 and under) (Leaving DHS) PR-1831 

ACCESS — Apply Online

Last Revised: February 17, 2009