Department of Health Services Logo

 

Wisconsin Department of Health Services

ForwardHealth Logo

Operations Memos

BadgerCare Plus Handbook

Medicaid Eligibility Handbook

FoodShare Wisconsin  Handbook

Income Maintenance Manual

Income Maintenance Forms

BadgerCare Plus  Publications

FoodShare  Publications

Medicaid Publications

Training

Eligibility Management (Income Maintenance) Home >> IM Forms

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

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 Title Form Number Form Type Revised Date Language 
Access Business Card P-16077 PDF 7/1/2007 English
Access Business Card - Spanish P-16077S PDF 9/1/2004 Spanish
Access Participant Brochure P-16080 PDF 8/1/2006 English
Access Participant Brochure - Spanish P-16080S PDF 4/1/2005 Spanish
Access Poster P-16084 PDF 7/1/2006 English
Access Poster - Spanish P-16084S PDF 3/1/2005 Spanish
Access Poster Tear Off Sheet P-16084A PDF 7/1/2006 English
Access Poster Tear Off Sheet - Spanish P-16084AS PDF 4/1/2008 Spanish
Administrative Disqualification Hearing Notice F-16038 pdf 7/1/2008 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 Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish F-14014AS PDF 7/1/2008 Spanish
Authorization to Request Birth Records F-00101 word 6/1/2009 English
BadgerCare Plus / Medicaid Health Insurance Information F-10115 pdf 7/1/2008 English
BadgerCare Plus / Medicaid Health Insurance Information - Spanish F-10115S pdf 7/1/2008 Spanish
Community Spouse Asset Share Notice F-10096 pdf 7/1/2008 English
Community Spouse Asset Share Notice - Spanish F-10096S pdf 7/1/2008 Spanish
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
ForwardHealth - Health Care for the Elderly, Blind and Disabled Application / Review Packet - Spanish F-10101S pdf 1/1/2009 Spanish
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 Divestment Penalty and Undue Hardship Notice F-10187 word 1/1/2009 English
ForwardHealth Enrollment and Benefits Handbook - Spanish P-00079S PDF 6/1/2009 Spanish
ForwardHealth Issuer of Annuity - Notice of Obligation F-10190 pdf 1/1/2009 English
ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs F-00163 PDF 9/1/2009 English
ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs F-00163 Word 9/1/2009 English
ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Completion Instructions F-00163I PDF 9/1/2009 English
ForwardHealth Prior Authorization Drug Attachment for Lovaza F-00162 PDF 9/1/2009 English
ForwardHealth Prior Authorization Drug Attachment for Lovaza F-00162 Word 9/1/2009 English
ForwardHealth Prior Authorization Drug Attachment for Lovaza Completion Instructions F-00162I PDF 9/1/2009 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
Health Care for Wisconsin Immigrants P-10164 PDF 10/1/2008 English
Health Care for Wisconsin Immigrants - Hmong P-10164H PDF 10/1/2008 Hmong
Health Care for Wisconsin Immigrants - Spanish P-10164S PDF 10/1/2008 Spanish
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
Information for Medicaid Disability Applicants - Spanish F-10113S PDF 7/1/2008 Spanish
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
Local Agency Customer Feedback - Spanish F-16104S Paper 1/1/2008 Spanish
Medicaid - Disability Application F-10112 pdf 7/1/2008 English
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 F-10126 pdf 7/1/2008 English
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong F-10126H pdf 7/1/2008 Hmong
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish F-10126S pdf 7/1/2008 Spanish
Medicaid / BadgerCare Plus and Family Planning Services Registration Application F-10129 pdf 6/1/2009 English
Medicaid / BadgerCare Plus and Family Planning Services Registration Application - Hmong F-10129H pdf 6/1/2009 Hmong
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 Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish F-10095S pdf 7/1/2008 Spanish
Medicaid Change Report F-10137 pdf 7/1/2008 English
Medicaid Change Report - Hmong F-10137H pdf 7/1/2008 Hmong
Medicaid Change Report - Russian F-10137R pdf 7/1/2008 Russian
Medicaid Change Report - Spanish F-10137S pdf 7/1/2008 Spanish
Medicaid Disability Redetermination Report F-10114 pdf 7/1/2008 English
Medicaid Income Allocation Notice F-10097 pdf 2/1/2009 English
Medicaid Income Allocation Notice - Spanish F-10097S pdf 2/1/2009 Spanish
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 Member Asset Allocation Notice - Spanish F-10098S pdf 2/1/2009 Spanish
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 - 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+) 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 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 Remaining Deductible Update F-10109 PDF 7/1/2008 English
Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish F-10129S pdf 1/1/2003 Spanish
MilES Key Contacts P-00087 PDF 6/1/2009 English
Negative Notice F-16001 pdf 7/1/2008 English
Negative Notice - Spanish F-16001S pdf 4/1/2006 Spanish
New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version F-10180 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
Positive Notice - Spanish F-16015S pdf 4/1/2006 Spanish
Self-Employment Income Report F-00107 pdf 8/1/2009 English
Self-Employment Income Report - Hmong F-00107H pdf 8/1/2009 Hmong
Self-Employment Income Report - Spanish F-00107S pdf 8/1/2009 Spanish
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
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 Children Under 18 Years of Age - Hmong F-10154H pdf 7/1/2008 Hmong
Statement of Identity for Children Under 18 Years of Age - Russian F-10154R pdf 7/1/2008 Russian
Statement of Identity for Children Under 18 Years of Age - Spanish F-10154S pdf 7/1/2008 Spanish
Statement of Identity for Persons in Institutional Care Facilities F-10175 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
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
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 for the Elderly, Blind and Disabled Application / Review Packet - Hmong F-10101H pdf 7/1/2008 Hmong
Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Russian F-10101R pdf 7/1/2008 Russian
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 pdf 7/1/2008 English
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish F-10140S pdf 7/1/2008 Spanish
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 English
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 Spanish