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Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: April 23, 2009

This list contains all Medicaid 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-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request pdf 12/1/2008 English
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-00162 ForwardHealth Prior Authorization Drug Attachment for Lovaza PDF 9/1/2009 English
F-00162 ForwardHealth Prior Authorization Drug Attachment for Lovaza Word 9/1/2009 English
F-00162I ForwardHealth Prior Authorization Drug Attachment for Lovaza Completion Instructions PDF 9/1/2009 English
F-00163 ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs PDF 9/1/2009 English
F-00163 ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Word 9/1/2009 English
F-00163I ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Completion Instructions PDF 9/1/2009 English
F-10075 Wisconsin Well Woman Medicaid Determination pdf 7/1/2009 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-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse pdf 7/1/2008 English
F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish pdf 7/1/2008 Spanish
F-10096 Community Spouse Asset Share Notice pdf 7/1/2008 English
F-10096S Community Spouse Asset Share Notice - Spanish pdf 7/1/2008 Spanish
F-10097 Medicaid Income Allocation Notice pdf 2/1/2009 English
F-10097S Medicaid Income Allocation Notice - Spanish pdf 2/1/2009 Spanish
F-10098 Medicaid Member Asset Allocation Notice pdf 2/1/2009 English
F-10098S Medicaid Member Asset Allocation Notice - Spanish pdf 2/1/2009 Spanish
F-10099 Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility pdf 7/1/2008 English
F-10101 ForwardHealth - Health Care for the Elderly, Blind and Disabled Application / Review Packet pdf 1/1/2009 English
F-10101H Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Hmong pdf 7/1/2008 Hmong
F-10101R Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Russian pdf 7/1/2008 Russian
F-10101S Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Spanish pdf 1/1/2009 Spanish
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice pdf 7/1/2008 English
F-10106S Medicaid Qualified Medicare Beneficiary (QMB) / Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice - Spanish pdf 7/1/2008 Spanish
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice pdf 7/1/2008 English
F-10107S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice - Spanish pdf 7/1/2008 Spanish
F-10108 Medicaid Manual Notice for Cost of Care Contribution pdf 7/1/2008 English
F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions PDF 7/1/2008 English
F-10109 Medicaid Remaining Deductible Update PDF 7/1/2008 English
F-10110 Medicaid / BadgerCare Plus Certification PDF 11/1/2008 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification pdf 7/1/2008 English
F-10111A Good Faith Medicaid Certification Instructions PDF 8/1/2003 English
F-10112 Medicaid - Disability Application pdf 7/1/2008 English
F-10112S Medicaid - Disability Application - Spanish pdf 7/1/2008 Spanish
F-10113 Information for Medicaid Disability Applicants PDF 7/1/2008 English
F-10113S Information for Medicaid Disability Applicants - Spanish PDF 7/1/2008 Spanish
F-10114 Medicaid Disability Redetermination Report pdf 7/1/2008 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-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration pdf 9/1/2008 English
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information pdf 7/1/2008 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-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  pdf 7/1/2008 English
F-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application pdf 6/1/2009 English
F-10129H Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong pdf 1/1/2003 Hmong
F-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish pdf 1/1/2003 Spanish
F-10130 Medicaid Presumptive Disability pdf 7/1/2008 English
F-10137 Medicaid Change Report pdf 7/1/2008 English
F-10137H Medicaid Change Report - Hmong pdf 7/1/2008 Hmong
F-10137R Medicaid Change Report - Russian pdf 7/1/2008 Russian
F-10137S Medicaid Change Report - Spanish pdf 7/1/2008 Spanish
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application pdf 7/1/2008 English
F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - 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-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant pdf 7/1/2008 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-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding PDF 7/1/2008 English
F-10146 Employment Verification of Earnings word 7/1/2008 English
F-10147 Wisconsin Veterans Home at King - Medicaid Review pdf 7/1/2008 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-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version pdf 7/1/2008 English
F-10187 ForwardHealth Divestment Penalty and Undue Hardship Notice word 1/1/2009 English
F-10188 ForwardHealth Undue Hardship Waiver Decision word 1/1/2009 English
F-10189 ForwardHealth Undue Hardship Bedhold Notice word 1/1/2009 English
F-10190 ForwardHealth Issuer of Annuity - Notice of Obligation pdf 1/1/2009 English
F-10191 ForwardHealth Annuity Beneficiary Designation pdf 1/1/2009 English
F-10192 ForwardHealth Annuity Information Disclosure pdf 1/1/2009 English
F-10193 ForwardHealth Undue Hardship Request pdf 1/1/2009 English
F-13023 Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  pdf 7/1/2008 English
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  pdf 7/1/2008 English
F-13039 Estate Recovery Program (ERP) Disclosure pdf 7/1/2008 English
F-13039A Estate Recovery Program (ERP) Disclosure Instructions PDF 7/1/2008 English
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) PDF 7/1/2008 English
F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish PDF 7/1/2008 Spanish
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-16021 Student Financial Report pdf 7/1/2008 English
F-16022 Social Security Number Referral pdf 7/1/2008 English
F-16031 Student Aid and Expense Worksheet 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
P-00079S ForwardHealth Enrollment and Benefits Handbook - Spanish PDF 6/1/2009 Spanish
P-00087 MilES Key Contacts PDF 6/1/2009 English
P-10164 Health Care for Wisconsin Immigrants PDF 10/1/2008 English
P-10164H Health Care for Wisconsin Immigrants - Hmong PDF 10/1/2008 Hmong
P-10164S Health Care for Wisconsin Immigrants - Spanish PDF 10/1/2008 Spanish
P-16077 Access Business Card PDF 7/1/2007 English
P-16077S Access Business Card - Spanish PDF 9/1/2004 Spanish
P-16080 Access Participant Brochure PDF 8/1/2006 English
P-16080S Access Participant Brochure - Spanish PDF 4/1/2005 Spanish
P-16084 Access Poster PDF 7/1/2006 English
P-16084A Access Poster Tear Off Sheet PDF 7/1/2006 English
P-16084AS Access Poster Tear Off Sheet - Spanish PDF 4/1/2008 Spanish
P-16084S Access Poster - Spanish PDF 3/1/2005 Spanish