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Eligibility Management (Income Maintenance)Home >> IM Forms

All Income Maintenance (IM) Forms
Sorted by Language

Last Revised: April 23, 2009

This list contains all DHCAA forms that are available from this site sorted by the language in which they are written. 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.

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