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Eligibility Management (Income Maintenance) Home >> IM Forms

All Income Maintenance (IM) Forms
Sorted by Form Type

Last Revised: April 23, 2009

This list contains all DHCAA forms that are available from this site sorted by the format (Excel, Paper only, PDF, Word). 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 Type Form Title Form Number Revised Date Language
Paper BadgerCare Plus - Express Enrollment for Pregnant Women Application F-10081 10/1/2008 English
Paper Local Agency Customer Feedback - Spanish F-16104S 1/1/2008 Spanish
Paper Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan F-10119 1/1/2009 English
pdf Administrative Disqualification Hearing Notice F-16038 7/1/2008 English
pdf Affidavit of Lost Income or Disaster Related Costs F-16106 7/1/2008 English
pdf Affidavit of Lost Income or Disaster-Related Costs - Spanish F-16106S 7/1/2008 Spanish
pdf Affidavit of Return or Exchange of Food Coupons F-09002 12/1/1997 English
PDF Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding F-10145 7/1/2008 English
PDF Agency Position on the Payment Error Rate Measurement (PERM) Error Finding F-10171 7/1/2008 English
PDF Authorization to Disclose Information to Disability Determination Bureau (DDB) F-14014 7/1/2008 English
PDF Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish F-14014AS 7/1/2008 Spanish
pdf BadgerCare Plus / Medicaid Health Insurance Information F-10115 7/1/2008 English
pdf BadgerCare Plus / Medicaid Health Insurance Information - Spanish F-10115S 7/1/2008 Spanish
pdf BadgerCare Plus Application / Review Packet F-10182 10/1/2008 English
pdf BadgerCare Plus Application / Review Packet - Spanish F-10182S 10/1/2008 Spanish
pdf BadgerCare Plus Application Packet - Hmong F-10182H 7/1/2008 Hmong
pdf BadgerCare Plus Change Report F-10183 7/1/2008 English
pdf BadgerCare Plus Change Report - Hmong F-10183H 7/1/2008 Hmong
pdf BadgerCare Plus Change Report - Spanish F-10183S 7/1/2008 Spanish
pdf BadgerCare Plus Premium Employer Wage Withholding F-13025 7/1/2008 English
pdf BadgerCare Plus Premium Information F-10139 6/1/2009 English
pdf BadgerCare Plus Premium Information - Spanish F-10139S 7/1/2008 Spanish
pdf BadgerCare Plus Premium Member / Employer Electronic Funds Transfer F-13026 7/1/2008 English
pdf BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 7/1/2008 English
pdf Community Spouse Asset Share Notice F-10096 7/1/2008 English
pdf Community Spouse Asset Share Notice - Spanish F-10096S 7/1/2008 Spanish
pdf Designation of a BadgerCare Plus Essential Person F-10186 7/1/2008 English
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits F-16004 7/1/2008 English
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - - Hmong F-16004H 7/1/2008 Hmong
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Russian F-16004R 7/1/2008 Russian
pdf Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish F-16004S 7/1/2008 Spanish
pdf Disaster FoodShare Notice F-16105 7/1/2008 English
pdf Disaster FoodShare Wisconsin Assistance Application F-16060 7/1/2008 English
pdf Disaster FoodShare Wisconsin Assistance Application - Spanish F-16060S 7/1/2008 Spanish
pdf Disqualification Consent Agreement F-16025 7/1/2008 English
pdf Disqualification Consent Agreement - Spanish F-16025S 7/1/2008 Spanish
pdf Estate Recovery Program (ERP) Disclosure F-13039 7/1/2008 English
PDF Estate Recovery Program (ERP) Disclosure Instructions F-13039A 7/1/2008 English
pdf FoodShare and/or Child Care Six Month Report F-16076 7/1/2008 English
pdf FoodShare and/or Child Care Six Month Report - Spanish F-16076S 7/1/2008 Spanish
PDF FoodShare and/or Child Care Six Month Report Form Instructions F-16076A 7/1/2008 English
PDF FoodShare and/or Child Care Six Month Report Form Instructions - Spanish F-16076AS 7/1/2008 Spanish
PDF FoodShare Employment and Training (FSET) Participation Agreement F-00136 7/1/2009 English
pdf FoodShare Employment and Training (FSET) Participation Agreement - Hmong F-00136H 7/1/2009 Hmong
pdf FoodShare Employment and Training (FSET) Participation Agreement - Spanish F-00136S 7/1/2009 Spanish
pdf FoodShare Wisconsin Application / Registration F-16019B 10/1/2008 English
pdf FoodShare Wisconsin Application / Registration - Hmong F-16019BH 7/1/2008 Hmong
pdf FoodShare Wisconsin Application / Registration - Spanish F-16019BS 10/1/2008 Spanish
pdf FoodShare Wisconsin Change Report F-16006 8/1/2008 English
pdf FoodShare Wisconsin Change Report - Hmong F-16006H 7/1/2008 Hmong
pdf FoodShare Wisconsin Change Report - Russian F-16006R 7/1/2008 Russian
pdf FoodShare Wisconsin Change Report - Spanish F-16006S 7/1/2008 Spanish
pdf FoodShare Wisconsin Income Change Report F-16066 10/1/2008 English
pdf FoodShare Wisconsin Income Change Report - Hmong F-16066H 10/1/2008 Hmong
pdf FoodShare Wisconsin Income Change Report - Hmong F-16066R 10/1/2008 Russian
pdf FoodShare Wisconsin Income Change Report - Spanish F-16066S 10/1/2008 Spanish
PDF FoodShare Wisconsin Nonfinancial Worksheet F-16073 8/1/2008 English
pdf FoodShare Wisconsin Over Issuance Worksheet F-16030 10/1/2008 English
pdf FoodShare Wisconsin Registration / Important Information F-16019A 10/1/2008 English
pdf FoodShare Wisconsin Registration Important Information - Hmong F-16019AH 7/1/2008 Hmong
pdf FoodShare Wisconsin Registration Important Information - Russian F-16019AR 12/1/2004 Russian
pdf FoodShare Wisconsin Registration Important Information - Spanish F-16019AS 10/1/2008 Spanish
pdf FoodShare Wisconsin Repayment Agreement F-16029 7/1/2008 English
pdf FoodShare Wisconsin Repayment Agreement - Spanish F-16029S 7/1/2008 Spanish
pdf FoodShare Wisconsin Worksheet F-16033 10/1/2008 English
pdf ForwardHealth - Health Care for the Elderly, Blind and Disabled Application / Review Packet F-10101 1/1/2009 English
pdf ForwardHealth Annuity Beneficiary Designation F-10191 1/1/2009 English
pdf ForwardHealth Annuity Information Disclosure F-10192 1/1/2009 English
PDF ForwardHealth BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 10/1/2008 English
PDF ForwardHealth BadgerCare Plus Express Enrollment for Children and Application Packet for Partners and Providers F-10148 10/1/2008 English
PDF ForwardHealth BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers F-10177 10/1/2008 English
pdf ForwardHealth Issuer of Annuity - Notice of Obligation F-10190 1/1/2009 English
pdf ForwardHealth Undue Hardship Request F-10193 1/1/2009 English
pdf Good Faith Medicaid / BadgerCare Plus Certification F-10111 7/1/2008 English
PDF Good Faith Medicaid Certification Instructions F-10111A 8/1/2003 English
pdf Income Maintenance Quality Assurance (IMQA) Web Request F-16083 7/1/2008 English
PDF Information for Medicaid Disability Applicants F-10113 7/1/2008 English
PDF Information for Medicaid Disability Applicants - Spanish F-10113S 7/1/2008 Spanish
pdf Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant F-10142 7/1/2008 English
PDF Local Agency Customer Feedback F-16104 8/1/2007 English
pdf Medicaid - Disability Application F-10112 7/1/2008 English
pdf Medicaid - Disability Application - Spanish F-10112S 7/1/2008 Spanish
pdf Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S 7/1/2008 Spanish
pdf Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 7/1/2008 English
pdf Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong F-10126H 7/1/2008 Hmong
pdf Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish F-10126S 7/1/2008 Spanish
pdf Medicaid / BadgerCare Plus and Family Planning Services Registration Application F-10129 6/1/2009 English
PDF Medicaid / BadgerCare Plus Certification F-10110 11/1/2008 English
PDF Medicaid / BadgerCare Plus Fair Hearing Information F-10151 7/1/2008 English
pdf Medicaid / BadgerCare Plus Overpayment Notice F-10093 7/1/2008 English
pdf Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse F-10095 7/1/2008 English
pdf Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish F-10095S 7/1/2008 Spanish
pdf Medicaid Change Report F-10137 7/1/2008 English
pdf Medicaid Change Report - Hmong F-10137H 7/1/2008 Hmong
pdf Medicaid Change Report - Russian F-10137R 7/1/2008 Russian
pdf Medicaid Change Report - Spanish F-10137S 7/1/2008 Spanish
pdf Medicaid Disability Redetermination Report F-10114 7/1/2008 English
pdf Medicaid Income Allocation Notice F-10097 2/1/2009 English
pdf Medicaid Income Allocation Notice - Spanish F-10097S 2/1/2009 Spanish
pdf Medicaid Manual Notice for Cost of Care Contribution F-10108 7/1/2008 English
PDF Medicaid Manual Notice for Cost of Care Contribution Instructions F-10108A 7/1/2008 English
pdf Medicaid Member Asset Allocation Notice F-10098 2/1/2009 English
pdf Medicaid Member Asset Allocation Notice - Spanish F-10098S 2/1/2009 Spanish
pdf Medicaid Presumptive Disability F-10130 7/1/2008 English
pdf Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  F-10127 7/1/2008 English
pdf Medicaid Purchase Plan (MAPP) Independence Account Registration F-10121 9/1/2008 English
pdf Medicaid Purchase Plan (MAPP) Member / Premium Information F-10122 7/1/2008 English
pdf Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  F-13024 7/1/2008 English
pdf Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  F-13023 7/1/2008 English
pdf Medicaid Qualified Medicare Beneficiary (QMB) / Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice - Spanish F-10106S 7/1/2008 Spanish
pdf Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice F-10106 7/1/2008 English
pdf Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice F-10107 7/1/2008 English
pdf Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice - Spanish F-10107S 7/1/2008 Spanish
PDF Medicaid Remaining Deductible Update F-10109 7/1/2008 English
pdf Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong F-10129H 1/1/2003 Hmong
pdf Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish F-10129S 1/1/2003 Spanish
pdf Negative Notice F-16001 7/1/2008 English
pdf Negative Notice - Spanish F-16001S 4/1/2006 Spanish
pdf New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version F-10180 7/1/2008 English
pdf Notice of Disqualification F-16024 7/1/2008 English
pdf Notice of Disqualification - Spanish F-16024S 7/1/2008 Spanish
pdf Notice of FoodShare Over issuance F-16028 7/1/2008 English
pdf Notice of FoodShare Overissuance - Spanish F-16028S 7/1/2008 Spanish
pdf Notice of Program Violation F-16014 7/1/2008 English
pdf Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility F-10099 7/1/2008 English
pdf Positive Notice F-16015 7/1/2008 English
pdf Positive Notice - Spanish F-16015S 4/1/2006 Spanish
pdf Prosecution Diversion Agreement F-16026 7/1/2008 English
pdf Quality Assurance (QA) Sample Check List F-16011 7/1/2008 English
pdf Quest Card and PIN Responsibility Statement F-16007 7/1/2008 English
pdf Quest Card and Pin Responsibility Statement - Hmong F-16007H 7/1/2008 Hmong
pdf Quest Card and Pin Responsibility Statement - Russian F-16007R 7/1/2008 English
pdf Quest Card and Pin Responsibility Statement - Spanish F-16007S 7/1/2008 English
pdf Self-Employment Income Report F-00107 8/1/2009 English
pdf Self-Employment Income Report - Hmong F-00107H 8/1/2009 Hmong
pdf Self-Employment Income Report - Spanish F-00107S 8/1/2009 Spanish
pdf Self-Employment Income Worksheet - Corporation F-16034 5/1/2009 English
pdf Self-Employment Income Worksheet - Partnership F-16036 5/1/2009 English
pdf Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 5/1/2009 English
pdf Self-Employment Income Worksheet - Subchapter S Corporation F-16035 5/1/2009 English
PDF SeniorCare Application F-10076 7/1/2008 English
pdf SeniorCare Authorization of Representative F-10080 7/1/2008 English
PDF SeniorCare Instructions for Application Form F-10076A 7/1/2008 English
PDF SeniorCare Instructions for Application Form - Hmong F-10076AH 7/1/2008 Hmong
PDF SeniorCare Instructions for Application Form - Russian F-10076AR 7/1/2008 Russian
PDF SeniorCare Instructions for Application Form - Spanish F-10076AS 7/1/2008 Spanish
pdf Social Security Number Referral F-16022 7/1/2008 English
pdf Statement of Citizenship and / or Identity for Special Populations F-10161 7/1/2008 English
pdf Statement of Identity for Children Under 18 Years of Age F-10154 7/1/2008 English
pdf Statement of Identity for Children Under 18 Years of Age - Hmong F-10154H 7/1/2008 Hmong
pdf Statement of Identity for Children Under 18 Years of Age - Russian F-10154R 7/1/2008 Russian
pdf Statement of Identity for Children Under 18 Years of Age - Spanish F-10154S 7/1/2008 Spanish
PDF Statement of Identity for Persons in Institutional Care Facilities F-10175 7/1/2008 English
pdf Striker Evaluation F-16023 7/1/2008 English
pdf Student Aid and Expense Worksheet F-16031 7/1/2008 English
pdf Student Financial Report F-16021 7/1/2008 English
PDF Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan Instructions F-10119A 1/1/2009 English
pdf Unprocessed Family Care, Pace, or Partnership Disenrollment Request F-00009 12/1/2008 English
pdf Verification of Veterans Benefits F-10162 7/1/2008 English
pdf Waiver of Administrative Disqualification Hearing F-16039 7/1/2008 English
pdf Waiver of Administrative Disqualification Hearing - Spanish F-16039S 7/1/2008 Spanish
pdf Wisconsin BadgerCare Plus Employer Verification of Health Insurance F-10181 7/1/2008 English
pdf Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice F-10143 7/1/2008 English
pdf Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 4/1/2009 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A 4/1/2009 English
pdf Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Hmong F-10101H 7/1/2008 Hmong
pdf Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Russian F-10101R 7/1/2008 Russian
pdf Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Spanish F-10101S 1/1/2009 Spanish
pdf Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 7/1/2008 English
pdf Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish F-10140S 7/1/2008 Spanish
pdf Wisconsin Veterans Home at King - Medicaid Review F-10147 7/1/2008 English
pdf Wisconsin Well Woman Medicaid Determination F-10075 7/1/2009 English
PDF Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin F-10150 7/1/2008 English
PDF Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish F-10150S 5/1/2007 Spanish
word Authorization to Request Birth Records F-00101 6/1/2009 English
word BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication F-10185 7/1/2008 English
word BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) F-10184 7/1/2008 English
word Employer Verification of Health Insurance F-10155 7/1/2008 English
word Employment Verification of Earnings F-10146 7/1/2008 English
word Enrollment Services Center State Vital Records Letter F-00100E 6/1/2009 English
word ForwardHealth BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 10/1/2008 English
word ForwardHealth BadgerCare Plus Express Enrollment for Children and Application Packet for Partners and Providers F-10148 10/1/2008 English
word ForwardHealth BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers F-10177 10/1/2008 English
word ForwardHealth Divestment Penalty and Undue Hardship Notice F-10187 1/1/2009 English
word ForwardHealth Undue Hardship Bedhold Notice F-10189 1/1/2009 English
word ForwardHealth Undue Hardship Waiver Decision F-10188 1/1/2009 English
word Life Insurance Inquiry F-10144 7/1/2008 English
word State Vital Records Cover Letter F-00100 6/1/2009 English
word Summary of Information Form Letter F-00098 6/1/2009 English