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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
BadgerCare Plus Forms Sorted by Form Number

Last Revised: June 03, 2009

This list contains BadgerCare Plus forms that are available from DHCAA. Forms marked as "PDF-Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form  Number Form Title Form Type Revised Date Language
F-00098 Summary of Information Form Letter word 6/1/2009 English
F-00100 State Vital Records Cover Letter word 6/1/2009 English
F-00100E Enrollment Services Center State Vital Records Letter word 6/1/2009 English
F-00101 Authorization to Request Birth Records word 6/1/2009 English
F-00107 Self-Employment Income Report pdf 8/1/2009 English
F-00107H Self-Employment Income Report - Hmong pdf 8/1/2009 Hmong
F-00107S Self-Employment Income Report - Spanish pdf 8/1/2009 Spanish
F-10081 BadgerCare Plus - Express Enrollment for Pregnant Women Application Paper 10/1/2008 English
F-10093 Medicaid / BadgerCare Plus Overpayment Notice pdf 7/1/2008 English
F-10093S Medicaid / BadgerCare Overpayment Notice - Spanish pdf 7/1/2008 Spanish
F-10110 Medicaid / BadgerCare Plus Certification PDF 11/1/2008 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification pdf 2/1/2009 English
F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions PDF 2/1/2009 English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information pdf 7/1/2008 English
F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish pdf 7/1/2008 Spanish
F-10119 Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan Paper 1/1/2009 English
F-10119A Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan Instructions PDF 1/1/2009 English
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative pdf 7/1/2008 English
F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong pdf 7/1/2008 Hmong
F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish pdf 7/1/2008 Spanish
F-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application pdf 6/1/2009 English
F-10129H Medicaid / BadgerCare Plus and Family Planning Services Registration Application - Hmong pdf 6/1/2009 Hmong
F-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish pdf 1/1/2003 Spanish
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application pdf 7/1/2008 English
F-10139 BadgerCare Plus Premium Information pdf 6/1/2009 English
F-10139S BadgerCare Plus Premium Information - Spanish pdf 7/1/2008 Spanish
F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request pdf 4/1/2009 English
F-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF 4/1/2009 English
F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice pdf 7/1/2008 English
F-10144 Life Insurance Inquiry word 7/1/2008 English
F-10146 Employment Verification of Earnings word 7/1/2008 English
F-10148 ForwardHealth BadgerCare Plus Express Enrollment for Children and Application Packet for Partners and Providers PDF 10/1/2008 English
F-10148 ForwardHealth BadgerCare Plus Express Enrollment for Children and Application Packet for Partners and Providers word 10/1/2008 English
F-10150 Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin PDF 7/1/2008 English
F-10150S Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish PDF 5/1/2007 Spanish
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information PDF 7/1/2008 English
F-10154 Statement of Identity for Children Under 18 Years of Age pdf 7/1/2008 English
F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong pdf 7/1/2008 Hmong
F-10154R Statement of Identity for Children Under 18 Years of Age - Russian pdf 7/1/2008 Russian
F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish pdf 7/1/2008 Spanish
F-10155 Employer Verification of Health Insurance word 7/1/2008 English
F-10161 Statement of Citizenship and / or Identity for Special Populations pdf 7/1/2008 English
F-10162 Verification of Veterans Benefits pdf 7/1/2008 English
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding PDF 7/1/2008 English
F-10175 Statement of Identity for Persons in Institutional Care Facilities PDF 7/1/2008 English
F-10176 ForwardHealth BadgerCare Plus Express Enrollment Change Request for Partners / Providers PDF 10/1/2008 English
F-10176 ForwardHealth BadgerCare Plus Express Enrollment Change Request for Partners / Providers word 10/1/2008 English
F-10177 ForwardHealth BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers PDF 10/1/2008 English
F-10177 ForwardHealth BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers word 10/1/2008 English
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version pdf 7/1/2008 English
F-10181 Wisconsin BadgerCare Plus Employer Verification of Health Insurance pdf 7/1/2008 English
F-10182 BadgerCare Plus Application / Review Packet pdf 10/1/2008 English
F-10182H BadgerCare Plus Application Packet - Hmong pdf 7/1/2008 Hmong
F-10182S BadgerCare Plus Application / Review Packet - Spanish pdf 10/1/2008 Spanish
F-10183 BadgerCare Plus Change Report pdf 7/1/2008 English
F-10183H BadgerCare Plus Change Report - Hmong pdf 7/1/2008 Hmong
F-10183S BadgerCare Plus Change Report - Spanish pdf 7/1/2008 Spanish
F-10184 BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) word 7/1/2008 English
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication word 7/1/2008 English
F-10186 Designation of a BadgerCare Plus Essential Person pdf 7/1/2008 English
F-13025 BadgerCare Plus Premium Employer Wage Withholding pdf 7/1/2008 English
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer pdf 7/1/2008 English
F-16001 Negative Notice pdf 7/1/2008 English
F-16001S Negative Notice - Spanish pdf 4/1/2006 Spanish
F-16014 Notice of Program Violation pdf 7/1/2008 English
F-16015 Positive Notice pdf 7/1/2008 English
F-16015S Positive Notice - Spanish pdf 4/1/2006 Spanish
F-16022 Social Security Number Referral pdf 7/1/2008 English
F-16034 Self-Employment Income Worksheet - Corporation pdf 5/1/2009 English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation pdf 5/1/2009 English
F-16036 Self-Employment Income Worksheet - Partnership pdf 5/1/2009 English
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business pdf 5/1/2009 English
F-16038 Administrative Disqualification Hearing Notice pdf 7/1/2008 English
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request pdf 7/1/2008 English
F-16104 Local Agency Customer Feedback PDF 8/1/2007 English
F-16104S Local Agency Customer Feedback - Spanish Paper 1/1/2008 Spanish