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Forms: Numeric List 
F-10000 Through F-19999

This numeric list contains forms that are available from this site.  A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms.   Microsoft Word - Fillable or Excel forms, 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.
Division Prefix / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
DHCAA F-10025 Case Management Terms of Reimbursement System Provider Services English
HCF-10075 F-10075 Wisconsin Well Woman Medicaid Determination pdf Forms Center English
HCF-10076 F-10076 SeniorCare Application PDF Forms Center English
HCF-10076A F-10076A SeniorCare Instructions for Application Form PDF Forms Center English
HCF-10076AH F-10076AH SeniorCare Instructions for Application Form - Hmong PDF None Hmong
HCF-10076AR F-10076AR SeniorCare Instructions for Application Form - Russian PDF None Russian
HCF-10076AS F-10076AS SeniorCare Instructions for Application Form - Spanish PDF None Spanish
HCF-10080 F-10080 SeniorCare Authorization of Representative pdf None English
HCF-10081 F-10081 BadgerCare Plus - Express Enrollment for Pregnant Women Application Paper Forms Center English
HCF-10093 F-10093 Medicaid / BadgerCare Plus Overpayment Notice pdf None English
HCF-10093S F-10093S Medicaid / BadgerCare Overpayment Notice - Spanish pdf None Spanish
HCF-10095 F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse pdf None English
HCF-10095S F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish pdf None Spanish
HCF-10096 F-10096 Community Spouse Asset Share Notice pdf None English
DHCAA F-10096S Community Spouse Asset Share Notice - Spanish pdf None Spanish
HCF-10097 F-10097 Medicaid Income Allocation Notice pdf None English
DHCAA F-10097S Medicaid Income Allocation Notice - Spanish pdf None Spanish
HCF-10098 F-10098 Medicaid Member Asset Allocation Notice pdf None English
DHCAA F-10098S Medicaid Member Asset Allocation Notice - Spanish pdf None Spanish
HCF-10099 F-10099 Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility pdf None English
HCF-10101 F-10101 ForwardHealth - Health Care for the Elderly, Blind and Disabled Application / Review Packet pdf Forms Center English
HCF-10101H F-10101H Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Hmong pdf None Hmong
HCF-10101R F-10101R Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet - Russian pdf None Russian
HCF-10101S F-10101S ForwardHealth - Health Care for the Elderly, Blind and Disabled Application / Review Packet - Spanish pdf None Spanish
HCF-10106 F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice pdf None English
HCF-10106S 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 None Spanish
HCF-10107 F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice pdf None English
DHCAA 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 None Spanish
HCF-10108 F-10108 Medicaid Manual Notice for Cost of Care Contribution pdf None English
HCF-10108A F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions PDF None English
HCF-10109 F-10109 Medicaid Remaining Deductible Update PDF Forms Center English
HCF-10110 F-10110 Medicaid / BadgerCare Plus Certification PDF None English
HCF-10111 F-10111 Good Faith Medicaid / BadgerCare Plus Certification pdf None English
HCF-10111A F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions PDF None English
HCF-10112 F-10112 Medicaid - Disability Application pdf Forms Center English
HCF-10112S F-10112S Medicaid - Disability Application - Spanish pdf None Spanish
HCF-10113 F-10113 Information for Medicaid Disability Applicants PDF Forms Center English
HCF-10113S F-10113S Information for Medicaid Disability Applicants - Spanish PDF None Spanish
HCF-10114 F-10114 Medicaid Disability Redetermination Report pdf None English
HCF-10115 F-10115 BadgerCare Plus / Medicaid Health Insurance Information pdf None English
HCF-10115S F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish pdf None Spanish
HCF-10119 F-10119 Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan Paper Forms Center English
HCF-10119A F-10119A Temporary Enrollment for BadgerCare Plus Family Planning Waiver Plan Instructions PDF None English
HCF-10121 F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration pdf None English
HCF-10122 F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information pdf None English
HCF-10126 F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative pdf None English
HCF-10126H F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong pdf None Hmong
HCF-10126S F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish pdf None Spanish
HCF-10127 F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  pdf None English
HCF-10129 F-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application pdf None English
HCF-10129H F-10129H Medicaid / BadgerCare Plus and Family Planning Services Registration Application - Hmong pdf None Hmong
HCF-10129S F-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish pdf None Spanish
HCF-10130 F-10130 Medicaid Presumptive Disability pdf None English
HCF-10137 F-10137 Medicaid Change Report pdf Forms Center English
HCF-10137H F-10137H Medicaid Change Report - Hmong pdf None Hmong
HCF-10137R F-10137R Medicaid Change Report - Russian pdf None Russian
HCF-10137S F-10137S Medicaid Change Report - Spanish pdf None Spanish
HCF-10138 F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application pdf None English
HCF-10139 F-10139 BadgerCare Plus Premium Information pdf None English
HCF-10139S F-10139S BadgerCare Plus Premium Information - Spanish pdf None Spanish
HCF-10140 F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application pdf None English
HCF-10140S F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish pdf None Spanish
HCF-10141 F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request pdf None English
HCF-10141A F-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF None English
HCF-10142 F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant pdf None English
HCF-10143 F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice pdf None English
HCF-10144 F-10144 Life Insurance Inquiry word None English
HCF-10145 F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding PDF None English
HCF-10146 F-10146 Employment Verification of Earnings word None English
HCF-10147 F-10147 Wisconsin Veterans Home at King - Medicaid Review pdf None English
HCF-10148 F-10148 ForwardHealth BadgerCare Plus Express Enrollment for Children and Application Packet for Partners and Providers PDF None English
HCF-10148 F-10148 ForwardHealth BadgerCare Plus Express Enrollment for Children and Application Packet for Partners and Providers word None English
HCF-10150 F-10150 Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin PDF None English
HCF-10150S F-10150S Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish PDF None Spanish
HCF-10151 F-10151 Medicaid / BadgerCare Plus Fair Hearing Information PDF None English
HCF-10154 F-10154 Statement of Identity for Children Under 18 Years of Age pdf None English
HCF-10154H F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong pdf None Hmong
HCF-10154R F-10154R Statement of Identity for Children Under 18 Years of Age - Russian pdf None Russian
HCF-10154S F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish pdf None Spanish
HCF-10155 F-10155 Employer Verification of Health Insurance word None English
HCF-10161 F-10161 Statement of Citizenship and / or Identity for Special Populations pdf None English
HCF-10162 F-10162 Verification of Veterans Benefits pdf None English
HCF-10171 F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding PDF None English
HCF-10172 F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding pdf None English
HCF-10175 F-10175 Statement of Identity for Persons in Institutional Care Facilities PDF None English
HCF-10176 F-10176 ForwardHealth BadgerCare Plus Express Enrollment Change Request for Partners / Providers PDF None English
HCF-10176 F-10176 ForwardHealth BadgerCare Plus Express Enrollment Change Request for Partners / Providers word None English
HCF-10177 F-10177 ForwardHealth BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers PDF None English
HCF-10177 F-10177 ForwardHealth BadgerCare Plus Express Enrollment for Pregnant Women and Application Packet for Qualified Providers word None English
HCF-10180 F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version pdf None English
HCF-10181 F-10181 Wisconsin BadgerCare Plus Employer Verification of Health Insurance pdf None English
HCF-10182 F-10182 BadgerCare Plus Application / Review Packet pdf Forms Center English
HCF-10182H F-10182H BadgerCare Plus Application Packet - Hmong pdf None Hmong
HCF-10182S F-10182S BadgerCare Plus Application / Review Packet - Spanish pdf None Spanish
HCF-10183 F-10183 BadgerCare Plus Change Report pdf Forms Center English
HCF-10183H F-10183H BadgerCare Plus Change Report - Hmong pdf Forms Center Hmong
HCF-10183S F-10183S BadgerCare Plus Change Report - Spanish pdf Forms Center Spanish
HCF-10184 F-10184 BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) word None English
HCF-10185 F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication word None English
HCF-10186 F-10186 Designation of a BadgerCare Plus Essential Person pdf None English
DHCAA F-10187 ForwardHealth Divestment Penalty and Undue Hardship Notice word None English
DHCAA F-10188 ForwardHealth Undue Hardship Waiver Decision word None English
DHCAA F-10189 ForwardHealth Undue Hardship Bedhold Notice word None English
DHCAA F-10190 ForwardHealth Issuer of Annuity - Notice of Obligation pdf None English
DHCAA F-10191 ForwardHealth Annuity Beneficiary Designation pdf None English
DHCAA F-10192 ForwardHealth Annuity Information Disclosure pdf None English
DHCAA F-10193 ForwardHealth Undue Hardship Request pdf None English
HCF-11001 F-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet pdf None English
HCF-11001 F-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet word None English
DHCAA F-11001A Wisconsin Medicaid Out-of-State Provider Data Sheet Completion Instructions PDF None English
HCF-11002 F-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet pdf None English
HCF-11002 F-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet word None English
DHCAA F-11002A Wisconsin Medicaid In-State Emergency Provider Data Sheet Completion Instructions PDF None English
HCF-11003 F-11003 Wisconsin Medicaid Provider Application Information and Instructions System Provider Services English
HCF-11004 F-11004 Wisconsin Medicaid Provider Application Mental Health Substance Abuse Agency Services Information and Instructions System Provider Services English
HCF-11005 F-11005 Wisconsin Medicaid Provider Application Mental Health Substance Abuse Individual Services (for Non-Physicians) Information and Instructions System Provider Services English
HCF-11007 F-11007 Wisconsin Medicaid Nursing Home Provider Application Information and Instructions System Provider Services English
HCF-11008 F-11008 Wisconsin Medicaid Prior Authorization / Therapy Attachment (PA/TA) pdf None English
HCF-11008 F-11008 Wisconsin Medicaid Prior Authorization / Therapy Attachment (PA/TA) word None English
HCF-11008A F-11008A Wisconsin Medicaid Prior Authorization / Therapy Attachment (PA/TA) Completion Instructions PDF None English
HCF-11010 F-11010 Wisconsin Medicaid Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format pdf None English
HCF-11010 F-11010 Wisconsin Medicaid Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format word None English
HCF-11010A F-11010A Wisconsin Medicaid Prior Authorization / Dental Attachment 1 (PA/DA1) Completion Instructions PDF None English
HCF-11011 F-11011 Wisconsin Medicaid Prior Authorization / Birth to 3 Attachment (PA/B3) pdf None English
HCF-11011 F-11011 Wisconsin Medicaid Prior Authorization / Birth to 3 Attachment (PA/B3) word None English
HCF-11013 F-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet pdf None English
HCF-11013 F-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet word None English
HCF-11013A F-11013A ForwardHealth Urgent Care Dental In-State Emergency Provider Data Sheet Completion Instructions PDF None English
HCF-11014 F-11014 Wisconsin Medicaid Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services pdf None English
HCF-11014 F-11014 Wisconsin Medicaid Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services word None English
HCF-11015 F-11015 Wisconsin Medicaid Deletion from Publications Mailing List System Provider Services English
HCF-11016 F-11016 Wisconsin Medicaid Prior Authorization Physician Attachment (PA/PA) pdf None English
HCF-11016 F-11016 Wisconsin Medicaid Prior Authorization Physician Attachment (PA/PA) word None English
HCF-11016A F-11016A Wisconsin Medicaid Prior Authorization Physician Attachment (PA/PA) Completion Instructions PDF None English
HCF-11017 F-11017 Wisconsin Medicaid Hospital Provider Application Information and Instructions System Provider Services English
HCF-11018 F-11018 ForwardHealth Prior Authorization pdf None English
HCF-11018 F-11018 ForwardHealth Prior Authorization Request word None English
HCF-11019 F-11019 Wisconsin Medicaid Prior Authorization / Physician Otological Report (PA/POR) pdf None English
HCF-11019 F-11019 Wisconsin Medicaid Prior Authorization / Physician Otological Report (PA/POR) word None English
HCF-11019A F-11019A Wisconsin Medicaid Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions PDF None English
HCF-11020 F-11020 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) pdf None English
HCF-11020 F-11020 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) word None English
HCF-11020A F-11020A ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Instructions PDF None English
HCF-11021 F-11021 ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services pdf None English
HCF-11021 F-11021 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) word None English
HCF-11021A F-11021A ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services Completion Instructions pdf None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data pdf None English
HCF-11023 F-11023 Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Excel None English
HCF-11023A F-11023A Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Instructions PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs pdf None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs word None English
HCF-11025A F-11025A Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs Instructions PDF None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs pdf None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs word None English
HCF-11026A F-11026A Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Instructions PDF None English
HCF-11027 F-11027 Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Excel None English
HCF-11027A F-11027A Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Instructions PDF None English
HCF-11029 F-11029 Wisconsin Medicaid Prior Authorization / Chiropractic Attachment (PA/CA) pdf None English
HCF-11029 F-11029 Wisconsin Medicaid Prior Authorization / Chiropractic Attachment (PA/CA) word None English
HCF-11029A F-11029A Wisconsin Medicaid Prior Authorization / Chiropractic Attachment (PA/CA) PDF None English
HCF-11030 F-11030 Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) pdf None English
HCF-11030 F-11030 Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) word None English
HCF-11030A F-11030A Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Instructions PDF None English
HCF-11031 F-11031 Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA/PSYA) pdf None English
HCF-11031 F-11031 Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA/PSYA) word None English
HCF-11031A F-11031A Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA / PSYA) Completion Instructions PDF None English
HCF-11032 F-11032 Wisconsin Medicaid Prior Authorization / Substance Abuse Attachment (PA/SAA) pdf None English
HCF-11032 F-11032 Wisconsin Medicaid Prior Authorization / Substance Abuse Attachment (PA/SAA) word None English
HCF-11032A F-11032A Wisconsin Medicaid Prior Authorization / Substance Abuse Attachment (PA/SAA) Instructions PDF None English
HCF-11033 F-11033 Wisconsin Medicaid Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) pdf None English
HCF-11033 F-11033 Wisconsin Medicaid Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) word None English
HCF-11033A F-11033A Wisconsin Medicaid Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Completion Instructions PDF None English
HCF-11034 F-11034 Wisconsin Medicaid Prior Authorization / "J" Code Attachment (PA/JCA) pdf None English
HCF-11034 F-11034 Wisconsin Medicaid Prior Authorization / "J" Code Attachment (PA/JCA) word None English
HCF-11034A F-11034A Wisconsin Medicaid Prior Authorization / "J" Code Attachment (PA/JCA) Instructions PDF None English
HCF-11035 F-11035 ForwardHealth Prior Authorization Dental Request (PA / DRF) pdf None English
HCF-11035 F-11035 ForwardHealth Prior Authorization Dental Request Form word None English
HCF-11035A F-11035A ForwardHealth Prior Authorization Dental Request Form [PA / DRF] Completion Instructions PDF None English
HCF-11036 F-11036 ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) pdf None English
HCF-11036 F-11036 ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) word None English
HCF-11036A F-11036A Wisconsin Medicaid Prior Authorization / In-Home Treatment Attachment (PA/ITA) Completion Instructions PDF None English
HCF-11037 F-11037 Wisconsin Medicaid Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) pdf None English
HCF-11037 F-11037 Wisconsin Medicaid Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) word None English
HCF-11037A F-11037A Wisconsin Medicaid Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Instructions PDF None English
HCF-11038 F-11038 Wisconsin Medicaid Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) pdf None English
HCF-11038 F-11038 Wisconsin Medicaid Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) word None English
HCF-11038A F-11038A Wisconsin Medicaid Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Instructions PDF None English
HCF-11039 F-11039 Wisconsin Medicaid Prior Authorization / Spell of Illness Attachment (PA/SOIA) pdf None English
HCF-11039 F-11039 Wisconsin Medicaid Prior Authorization / Spell of Illness Attachment (PA/SOIA) word None English
HCF-11039A F-11039A Wisconsin Medicaid Prior Authorization / Spell of Illness Attachment (PA/SOIA) Completion Instructions PDF None English
HCF-11040 F-11040 Wisconsin Medicaid Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) pdf None English
HCF-11040 F-11040 Wisconsin Medicaid Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) word None English
HCF-11040A F-11040A Wisconsin Medicaid Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Completion Instructions PDF None English
HCF-11041 F-11041 Wisconsin Medicaid Private Duty Nursing Prior Authorization Acknowledgment pdf None English
HCF-11041 F-11041 Wisconsin Medicaid Private Duty Nursing Prior Authorization Acknowledgment word None English
HCF-11042 F-11042 Wisconsin Medicaid Prior Authorization Amendment Request pdf None English
HCF-11042 F-11042 Wisconsin Medicaid Prior Authorization Amendment Request word None English
HCF-11042A F-11042A Wisconsin Medicaid Prior Authorization Amendment Request Completion Instructions PDF None English
HCF-11044 F-11044 Wisconsin Medicaid Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) pdf None English
HCF-11044 F-11044 Wisconsin Medicaid Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) word None English
HCF-11044A F-11044A Wisconsin Medicaid Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Completion Instructions PDF None English
HCF-11047 F-11047 Wisconsin Medicaid Certification of Need for Elective / Urgent Psychiatric / Substance Abuse pdf None English
HCF-11048 F-11048 Wisconsin Medicaid Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission pdf None English
HCF-11049 F-11049 Wisconsin Medicaid Prior Authorization / Drug Attachment (PA/DGA) pdf None English
HCF-11049 F-11049 Wisconsin Medicaid Prior Authorization / Drug Attachment (PA/DGA) word None English
HCF-11049A F-11049A Wisconsin Medicaid Prior Authorization / Drug Attachment (PA/DGA) Completion Instructions PDF None English
HCF-11051 F-11051 Wisconsin Medicaid Prior Authorization / Vision Services Attachment (PA/VA) pdf None English
HCF-11051 F-11051 Wisconsin Medicaid Prior Authorization / Vision Services Attachment (PA/VA) word None English
HCF-11051A F-11051A Wisconsin Medicaid Prior Authorization / Vision Services Attachment (PA/VA) Completion Instructions PDF None English
HCF-11052 F-11052 ForwardHealth STAT-PA Orthopedic Shoes Worksheet pdf None English
HCF-11052 F-11052 ForwardHealth STAT-PA Orthopedic Shoes Worksheet word None English
HCF-11052A F-11052A ForwardHealth STAT-PA Orthopedic Shoes Worksheet Completion Instructions PDF None English
HCF-11054 F-11054 Wisconsin Medicaid Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) pdf None English
HCF-11054 F-11054 Wisconsin Medicaid Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) word None English
HCF-11054A F-11054A Wisconsin Medicaid Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Completion Instructions PDF None English
HCF-11055 F-11055 Wisconsin Medicaid STAT-PA Pharmacy Drug Worksheet Instructions PDF None English
HCF-11056 F-11056 ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors pdf None English
HCF-11056 F-11056 ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors word None English
HCF-11056A F-11056A ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors Completion Instructions PDF None English
HCF-11062 F-11062 ForwardHealth Prior Authorization / Environmental Lead Inspection pdf None English
HCF-11062 F-11062 ForwardHealth Prior Authorization / Environmental Lead Inspection word None English
HCF-11062A F-11062A ForwardHealth Prior Authorization / Environmental Lead Inspection Instructions for Paper Prior Authorization or STAT-PA PDF None English
HCF-11066 F-11066 Wisconsin Medicaid Prior Authorization / Oxygen Attachment (PA/OA) pdf None English
HCF-11066 F-11066 Wisconsin Medicaid Prior Authorization / Oxygen Attachment (PA/OA) word None English
HCF-11066A F-11066A Wisconsin Medicaid Prior Authorization / Oxygen Attachment (PA/OA) Completion Instructions PDF None English
HCF-11067 F-11067 Wisconsin Medicaid Record of Actual Daily Oxygen Use pdf None English
HCF-11067 F-11067 Wisconsin Medicaid Record of Actual Daily Oxygen Use word None English
HCF-11067A F-11067A ForwardHealth Record of Actual Daily Oxygen Use Completion Instructions PDF None English
HCF-11075 F-11075 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA PDL) Exemption Request pdf None English
HCF-11075 F-11075 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA PDL) Exemption Request word None English
HCF-11075A F-11075A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA PDL) Exemption Request Completion Instructions PDF None English
HCF-11076 F-11076 ForwardHealth Prior Authorization Request (PA / RF) Completion Instructions for Residential Care Center Treatment Services PDF None English
HCF-11076A F-11076A ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC pdf None English
HCF-11076A F-11076A ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC word None English
HCF-11076B F-11076B ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services PDF None English
HCF-11076B F-11076B ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services word None English
HCF-11076C F-11076C ForwardHealth Prior Authorization / Residential Care Center Treatment Attachment (PA / RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services PDF None English
HCF-11077 F-11077 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors pdf None English
HCF-11077 F-11077 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors word None English
HCF-11077A F-11077A ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors Completion Instructions PDF None English
HCF-11078 F-11078 ForwardHealth BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs pdf None English
HCF-11078 F-11078 ForwardHealth BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs word None English
HCF-11078A F-11078A ForwardHealth BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions PDF None English
HCF-11079 F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Excel None English
HCF-11079A F-11079A Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Completion Instructions PDF None English
HCF-11080 F-11080 Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Excel None English
HCF-11080A F-11080A Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Completion Instructions PDF None English
DHCAA F-11080CA Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Completion Instructions PDF None English
DHCAA F-11080CP Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Excel None English
HCF-11081 F-11081 Wisconsin Medicaid Rural Health Clinic Provider Staff Encounters Excel None English
HCF-11083 F-11083 BadgerCare Plus Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) pdf None English
HCF-11083 F-11083 BadgerCare Plus Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) word None English
HCF-11083A F-11083A BadgerCare Plus Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) Completion Instructions PDF None English
HCF-11088 F-11088 Wisconsin Medicaid Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) pdf None English
HCF-11088 F-11088 Wisconsin Medicaid Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) word None English
HCF-11088A F-11088A Wisconsin Medicaid Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Completion Instructions PDF None English
HCF-11090 F-11090 Wisconsin Medicaid Mental Health Day Treatment Functional Assessment pdf None English
HCF-11090 F-11090 Wisconsin Medicaid Mental Health Day Treatment Functional Assessment word None English
HCF-11090A F-11090A Wisconsin Medicaid Mental Health Day Treatment Functional Assessment Completion Instructions PDF None English
HCF-11092 F-11092 ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs pdf None English
HCF-11092 F-11092 ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs word None English
HCF-11092A F-11092A ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Completion Instructions PDF None English
HCF-11096 F-11096 Wisconsin Medicaid Prior Authorization / Home Care Attachment (PA/HCA) pdf None English
HCF-11096 F-11096 Wisconsin Medicaid Prior Authorization / Home Care Attachment (PA/HCA) word None English
HCF-11096A F-11096A Wisconsin Medicaid Prior Authorization / Home Care Attachment (PA/HCA) Completion Instructions PDF None English
HCF-11097 F-11097 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents pdf None English
HCF-11097 F-11097 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents word None English
HCF-11097A F-11097A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents Completion Instructions PDF None English
HCF-11103 F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (Optional) pdf None English
HCF-11103 F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (Optional) word None English
HCF-11103A F-11103A Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Completion Instructions (Optional Form) PDF None English
HCF-11105 F-11105 Model Plan: In-Home Mental Health / Substance Abuse Treatment Services pdf None English
HCF-11105 F-11105 Model Plan: In-Home Mental Health / Substance Abuse Treatment Services word None English
HCF-11106 F-11106 Model Multi-Agency Treatment Plan pdf None English
HCF-11106 F-11106 Model Multi-Agency Treatment Plan word None English
HCF-11129A F-11129A Wisconsin Medicaid Federally Qualified Health Center Cost Report Completion Instructions PDF None English
HCF-11129B-H F-11129B-H Wisconsin Medicaid Federally Qualified Health Center Cost Report Forms Excel None English
HCF-11130 F-11130 Wisconsin Medicaid Federally Qualified Health Center Interim Report Excel None English
HCF-11130A F-11130A Wisconsin Medicaid Federally Qualified Health Center Interim Report Completion Instructions PDF None English
HCF-11133 F-11133 ForwardHealth Personal Care Screening Tool (PCST) PDF None English
HCF-11133 F-11133 ForwardHealth Personal Care Screening Tool (PCST) word None English
HCF-11133A F-11133A ForwardHealth Personal Care Screening Tool (PCST) Completion Instructions PDF None English
HCF-11134 F-11134 Wisconsin Medicaid Personal Care Prior Authorization Provider Acknowledgement pdf None English
HCF-11134 F-11134 Wisconsin Medicaid Personal Care Prior Authorization Provider Acknowledgement word None English
HCF-11136 F-11136 Wisconsin Medicaid Personal Care Addendum pdf None English
HCF-11136 F-11136 Wisconsin Medicaid Personal Care Addendum word None English
HCF-11136A F-11136A Wisconsin Medicaid Personal Care Addendum Completion Instructions PDF None English
HCF-11233 F-11233 Wisconsin Medicaid Ambulance Provider Certification Packet System Provider Services English
HCF-11235 F-11235 Wisconsin Medicaid Ambulatory Surgery Center Provider Certification Packet System Provider Services English
HCF-11236 F-11236 Wisconsin Medicaid Anesthetist Provider Certification Packet System Provider Services English
HCF-11238 F-11238 Wisconsin Medicaid Audiology / Hearing Instrument Specialist / Speech Pathology Provider Certification Packet System Provider Services English
HCF-11239 F-11239 Wisconsin Medicaid Case Management Certification Packet System Provider Services English
HCF-11240 F-11240 Wisconsin Medicaid Case Management Provider Information System Provider Services English
HCF-11241 F-11241 Wisconsin Medicaid Chiropractic Certification Packet System Provider Services English
HCF-11242 F-11242 Wisconsin Medicaid Dental Certification Packet System Provider Services English
HCF-11243 F-11243 Wisconsin Medicaid End Stage Renal Disease Certification Packet System Provider Services English
HCF-11244 F-11244 Wisconsin Medicaid Family Planning Clinics Certification Packet System Provider Services English
HCF-11245 F-11245 Wisconsin Medicaid Family Planning Clinics or Agencies System Provider Services English
HCF-11246 F-11246 Wisconsin Medicaid Federally Qualified Health Center (FQHC) Certification Packet System Provider Services English
HCF-11247 F-11247 Services that can be billed under the Federally Qualified Health Center Clinic Number System Provider Services English
HCF-11248 F-11248 Services that can be billed under the Federally Qualified Health Center Assigned Clinic Number System Provider Services English
HCF-11249 F-11249 Wisconsin Medicaid HealthCheck (Other) Certification Packet System Provider Services English
HCF-11250 F-11250 Wisconsin Medicaid HealthCheck Screener Only Provider Certification Packet System Provider Services English
HCF-11251 F-11251 Wisconsin Medicaid Home Health Agency Provider Certification Packet System Provider Services English
DHCAA F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum System Provider Services English
HCF-11253 F-11253 Wisconsin Medicaid Hospice Provider Certification Packet System Provider Services English
HCF-11254 F-11254 Wisconsin Medicaid Hospital Provider Certification Packet System Provider Services English
HCF-11255 F-11255 Wisconsin Medicaid Independent Laboratory Certification Packet System Provider Services English
HCF-11256 F-11256 Wisconsin Medicaid Independent Nurse Certification Packet System Provider Services English
HCF-11257 F-11257 Wisconsin Medicaid Private Duty Nurse (PDN) Provider Addendum System Provider Services English
DHCAA F-11258 Wisconsin Medicaid Declaration of Skill Acquisition - Private Duty Nursing For Members Ventillator Dependent for Life-Support Adult (Age 17 and over) pdf None English
DHCAA F-11259 Wisconsin Medicaid Declaration of Skill Acquisition - Private Duty Nursing For Members Ventilator Dependent for Life-Support Pediatric (Age 0-16) pdf None English
DHCAA F-11260 Wisconsin Medicaid Degree Addendum System Provider Services English
HCF-11261 F-11261 Wisconsin Medicaid Medical Supply and Equipment Vendor Certification Packet System Provider Services English
HCF-11263 F-11263 Wisconsin Medicaid Mental Health Substance Abuse Individual Provider Certification Packet System Provider Services English
HCF-11264 F-11264 Wisconsin Medicaid Nurse Practitioner Provider Certification Packet System Provider Services English
HCF-11265 F-11265 Wisconsin Medicaid Nursing Home Provider Certification Packet System Provider Services English
HCF-11266 F-11266 Wisconsin Medicaid Occupational Therapy Provider Certification Packet System Provider Services English
HCF-11267 F-11267 Wisconsin Medicaid Mental Health Substance Abuse Agency Provider Certification Packet System Provider Services English
HCF-11268 F-11268 Wisconsin BadgerCare Plus Express Enrollment for Pregnant Women Certification Packet System Provider Services English
HCF-11270 F-11270 Wisconsin Medicaid Personal Care Agency Provider Certification Packet System Provider Services English
HCF-11271 F-11271 Wisconsin Medicaid Personal Care Addendum System Provider Services English
HCF-11272 F-11272 Wisconsin Medicaid Pharmacy Provider Certification Packet System Provider Services English
HCF-11273 F-11273 Wisconsin Medicaid Physician Therapy Certification Packet System Provider Services English
HCF-11274 F-11274 Wisconsin Medicaid Physician / Physician Assistant Certification Packet System Provider Services English
HCF-11275 F-11275 Wisconsin Medicaid Podiatry Certification Packet System Provider Services English
HCF-11276 F-11276 Wisconsin Medicaid Portable X-Ray Certification Packet System Provider Services English
HCF-11277 F-11277 Wisconsin Medicaid Pre-Natal Care Coordination Certification Packet System Provider Services English
HCF-11278 F-11278 Wisconsin Medicaid PreNatal Care Coordination Outreach and Management Plan System Provider Services English
DHCAA F-11279 Wisconsin Medicaid Memorandum of Understanding (Sample Format) Between HMO and PreNatal Care Coordination Agency System Provider Services English
HCF-11280 F-11280 Wisconsin Medicaid Rehabilitation Agency Certification Packet System Provider Services English
HCF-11281 F-11281 Wisconsin Medicaid Rural Health Clinic Certification Packet System Provider Services English
HCF-11282 F-11282 Wisconsin Medicaid School-Based Services Certification Packet System Provider Services English
HCF-11284 F-11284 Wisconsin Medicaid Specialized Medical Vehicle Certification Packet System Provider Services English
HCF-11285 F-11285 Wisconsin Medicaid HealthCheck Screener Affirmation System Provider Services English
HCF-11286 F-11286 Wisconsin Medicaid HealthCheck Screener Outreach Case Management Provider Certification Packet System Provider Services English
HCF-11288 F-11288 Wisconsin Medicaid Therapy Group Certification Packet System Provider Services English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan System Provider Services English
HCF-11290 F-11290 Wisconsin Medicaid HealthCheck Outreach Case Management Only Provider Certification Packet System Provider Services English
HCF-11303 F-11303 BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic pdf None English
HCF-11303 F-11303 BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic word None English
HCF-11303A F-11303A BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic Completion Instructions PDF None English
HCF-11304 F-11304 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis pdf None English
HCF-11304 F-11304 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis word None English
HCF-11304A F-11304A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Completion Instructions PDF None English
HCF-11305 F-11305 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease pdf None English
HCF-11305 F-11305 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease word None English
HCF-11305A F-11305A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease Completion Instructions PDF None English
HCF-11306 F-11306 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis pdf None English
HCF-11306 F-11306 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis word None English
HCF-11306A F-11306A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis Completion Instructions PDF None English
HCF-11307 F-11307 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis pdf None English
HCF-11307 F-11307 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis word None English
HCF-11307A F-11307A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis Completion Instructions PDF None English
HCF-11308 F-11308 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis pdf None English
HCF-11308 F-11308 Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis word None English
HCF-11308A F-11308A Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis Completion Instructions PDF None English
DHCAA F-11309 Wisconsin BadgerCare Plus Express Enrollment for All Children Certification Packet System Provider Services English
HCF-11317 F-11317 ForwardHealth Certification Criteria For Providers Express Enrollment of Pregnant Women in BadgerCare Plus PDF None English
HCF-11318 F-11318 ForwardHealth Certification Criteria For Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus PDF None English
HCF-12022 F-12022 Wisconsin Medicaid Managed Care Program Provider Appeal pdf None English
HCF-12022 F-12022 Wisconsin Medicaid Managed Care Program Provider Appeal word None English
HCF-12023 F-12023 Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption Paper MCE English
HCF-12023S F-12023S Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption - Spanish Paper MCE Spanish
HCF-12024 F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model Paper MC Enrollment Specialist English
HCF-12024A F-12024A Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model Completion Instructions Paper MC Enrollment Specialist English
HCF-12025 F-12025 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request Paper MC Consultant English
HCF-12025A F-12025A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request Completion Instructions Paper MC Consultant English
HCF-12027 F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request Paper MC Enrollment Specialist English
HCF-12027A F-12027A Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request Completion Instructions Paper MC Enrollment Specialist English
HCF-12028 F-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request Paper MC Enrollment Specialist English
HCF-12028A F-12028A Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request Completion Instructions Paper MC Enrollment Specialist English
HCF-12029 F-12029 Managed Care Disenrollment Request Paper MC Enrollment Specialist English
HCF-12081 F-12081 Wisconsin Medicaid Health Information Exchange Facility Security and Confidentiality Agreement Paper Forms Manager English
HCF-12085 F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice Paper Forms Manager English
HCF-12089 F-12089 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request Paper MC Consultant English
HCF-12089A F-12089A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request Information and Instructions Paper MC Consultant English
HCF-13021 F-13021 Medicaid Purchase Plan Employer Verification of Insurance Coverage Paper Forms Manager English
HCF-13021A F-13021A Medicaid Purchase Plan Employer Verification of Insurance Coverage Instructions Paper Forms Manager English
HCF-13023 F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions pdf None English
HCF-13024 F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  pdf None English
HCF-13025 F-13025 BadgerCare Plus Premium Employer Wage Withholding pdf None English
HCF-13026 F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer pdf None English
HCF-13027 F-13027 Employer Verification of Insurance Coverage Paper Forms Manager English
HCF-13027A F-13027A Employer Verification of Insurance Coverage Instructions Paper Forms Manager English
HCF-13033 F-13033 Probate Claims Notice pdf None English
HCF-13038 F-13038 Notice of Intent to File a Lien Paper Forms Center English
HCF-13039 F-13039 Estate Recovery Program (ERP) Disclosure pdf None English
HCF-13039A F-13039A Estate Recovery Program (ERP) Disclosure Instructions PDF None English
HCF-13043 F-13043 ForwardHealth Trading Partner Profile pdf None English
HCF-13043A F-13043A ForwardHealth Trading Partner Profile Completion Instructions PDF None English
HCF-13046 F-13046 Wisconsin Medicaid Adjustment / Reconsideration Request pdf None English
HCF-13046 F-13046 Wisconsin Medicaid Adjustment / Reconsideration Request word None English
HCF-13046A F-13046A Wisconsin Medicaid Adjustment / Reconsideration Request Completion Instructions PDF None English
HCF-13047 F-13047 Wisconsin Medicaid Timely Filing Appeals Request pdf None English
HCF-13047 F-13047 Wisconsin Medicaid Timely Filing Appeals Request word None English
HCF-13066 F-13066 Wisconsin Medicaid Claim Refund pdf None English
HCF-13066 F-13066 Wisconsin Medicaid Claim Refund word None English
HCF-13066A F-13066A Wisconsin Medicaid Claim Refund Completion Instructions PDF None English
HCF-13072 F-13072 ForwardHealth Drug Claims - Noncompound Drug Claim pdf None English
HCF-13072 F-13072 ForwardHealth Drug Claims - Noncompound Drug Claim word None English
HCF-13072A F-13072A ForwardHealth Drug Claims - Noncompound Drug Claim Completion Instructions PDF None English
HCF-13073 F-13073 ForwardHealth Drug Claims - Compound Drug Claim pdf None English
HCF-13073 F-13073 ForwardHealth Drug Claims - Compound Drug Claim word None English
HCF-13073A F-13073A ForwardHealth Drug Claims - Compound Drug Claim Completion Instructions PDF None English
HCF-13074 F-13074 ForwardHealth Pharmacy Special Handling Request pdf None English
HCF-13074 F-13074 ForwardHealth Pharmacy Special Handling Request word None English
HCF-13074A F-13074A ForwardHealth Pharmacy Special Handling Request Completion Instructions PDF None English
HCF-13076 F-13076 ForwardHealth Managed Care Trading Partner Profile pdf None English
HCF-13076A F-13076A ForwardHealth Managed Care Trading Partner Profile Complete Instructions PDF None English
HCF-13145 F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure PDF None English
HCF-13146 F-13146 Wisconsin Medicaid HIPAA Privacy Revocation of Authorization PDF None English
HCF-13147 F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request PDF None English
HCF-13148 F-13148 Wisconsin Medicaid HIPAA Privacy Access Request PDF None English
HCF-13149 F-13149 Wisconsin Medicaid HIPAA Privacy Accounting Request PDF None English
HCF-13150 F-13150 Wisconsin Medicaid HIPAA Privacy Alternate Communication Request PDF None English
HCF-13151 F-13151 Wisconsin Medicaid HIPAA Privacy Amendment Request PDF None English
HCF-13152 F-13152 Wisconsin Medicaid HIPAA Privacy Complaint PDF None English
HCF-13153 F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure PDF None English
HCF-13154 F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request PDF None English
HCF-13155 F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request PDF None English
HCF-13156 F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request PDF None English
HCF-13157 F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request PDF None English
HCF-13158 F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint PDF None English
HCF-13159 F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request PDF None English
HCF-13160 F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization PDF None English
HCF-13161 F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure PDF None English
HCF-13162 F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request PDF None English
HCF-13163 F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request PDF None English
HCF-13164 F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request PDF None English
HCF-13165 F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request PDF None English
HCF-13166 F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint PDF None English
HCF-13167 F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization PDF None English
HCF-13168 F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request PDF None English
HCF-13170 F-13170 Proprietary Electronic R and S Report Request Paper Forms Manager English
HCF-13171 F-13171 Proprietary Electronic R and S Report Discontinue Request Paper Forms Manager English
HCF-13174 F-13174 Estate Recovery Program Heir Information PDF None English
HCF-13175 F-13175 Medicaid / Family Care / Partnership / BadgerCare Plus / Estate Recovery Notification of Death pdf None English
HCF-13393 F-13393 ForwardHealth Trading Partner 835 Designation pdf None English
HCF-13393A F-13393A ForwardHealth Trading Partner 835 Designation Completion Instructions PDF None English
HCF-13470 F-13470 ForwardHealth Claim Form Attachment Cover Page pdf None English
HCF-13470 F-13470 ForwardHealth Claim Form Attachment Cover Page word None English
HCF-13470A F-13470A ForwardHealth Claim Forms Attachment Cover Page Completion Instructions Automated Form Letter PDF None English
HCF-13505 F-13505 ForwardHealth National Provider Identifier Collection pdf None English
HCF-13505 F-13505 Medicaid and BadgerCare Plus National Provider Identifier Collection word None English
DHCAA F-13509 Wisconsin Well Woman Program Provider Certification Packet System Provider Services English
DHCAA F-13607 Provider Participation Agreement - February 2008 System Provider Services English
HCF-13622 F-13622 ForwardHealth InterChange Implementation Transitional Payment Request pdf None English
HCF-13622 F-13622 ForwardHealth InterChange Implementation Transitional Payment Request word None English
HCF-14014 F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) PDF None English
HCF-14014AS F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish PDF None Spanish
HCF-16001 F-16001 Negative Notice pdf None English
HCF-16001S F-16001S Negative Notice - Spanish pdf None Spanish
HCF-16004 F-16004 Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits pdf None English
HCF-16004H F-16004H Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - - Hmong pdf None Hmong
HCF-16004R F-16004R Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Russian pdf None Russian
HCF-16004S F-16004S Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish pdf None Spanish
HCF-16006 F-16006 FoodShare Wisconsin Change Report pdf Forms Center English
HCF-16006H F-16006H FoodShare Wisconsin Change Report - Hmong pdf None Hmong
HCF-16006R F-16006R FoodShare Wisconsin Change Report - Russian pdf None Russian
HCF-16006S F-16006S FoodShare Wisconsin Change Report - Spanish pdf None Spanish
HCF-16007 F-16007 Quest Card and PIN Responsibility Statement pdf Forms Center English
HCF-16007H F-16007H Quest Card and Pin Responsibility Statement - Hmong pdf None Hmong
HCF-16007R F-16007R Quest Card and Pin Responsibility Statement - Russian pdf None English
HCF-16007S F-16007S Quest Card and Pin Responsibility Statement - Spanish pdf None English
HCF-16011 F-16011 Quality Assurance (QA) Sample Check List pdf None English
HCF-16014 F-16014 Notice of Program Violation pdf None English
HCF-16015 F-16015 Positive Notice pdf None English
HCF-16015S F-16015S Positive Notice - Spanish pdf None Spanish
HCF-16019A F-16019A FoodShare Wisconsin Registration / Important Information pdf Forms Center English
HCF-16019AH F-16019AH FoodShare Wisconsin Registration Important Information - Hmong pdf None Hmong
HCF-16019AR F-16019AR FoodShare Wisconsin Registration Important Information - Russian pdf None Russian
HCF-16019AS F-16019AS FoodShare Wisconsin Registration Important Information - Spanish pdf None Spanish
HCF-16019B F-16019B FoodShare Wisconsin Application / Registration pdf Forms Center English
HCF-16019BH F-16019BH FoodShare Wisconsin Application / Registration - Hmong pdf None Hmong
HCF-16019BS F-16019BS FoodShare Wisconsin Application / Registration - Spanish pdf None Spanish
HCF-16021 F-16021 Student Financial Report pdf None English
HCF-16022 F-16022 Social Security Number Referral pdf None English
HCF-16023 F-16023 Striker Evaluation pdf None English
HCF-16024 F-16024 Notice of Disqualification pdf None English
HCF-16024S F-16024S Notice of Disqualification - Spanish pdf None Spanish
HCF-16025 F-16025 Disqualification Consent Agreement pdf None English
HCF-16025S F-16025S Disqualification Consent Agreement - Spanish pdf None Spanish
HCF-16026 F-16026 Prosecution Diversion Agreement pdf None English
HCF-16028 F-16028 Notice of FoodShare Over issuance pdf None English
HCF-16028S F-16028S Notice of FoodShare Overissuance - Spanish pdf None Spanish
HCF-16029 F-16029 FoodShare Wisconsin Repayment Agreement pdf None English
HCF-16029S F-16029S FoodShare Wisconsin Repayment Agreement - Spanish pdf None Spanish
HCF-16030 F-16030 FoodShare Wisconsin Over Issuance Worksheet pdf None English
HCF-16031 F-16031 Student Aid and Expense Worksheet pdf None English
HCF-16033 F-16033 FoodShare Wisconsin Worksheet pdf None English
HCF-16034 F-16034 Self-Employment Income Worksheet - Corporation pdf None English
HCF-16035 F-16035 Self-Employment Income Worksheet - Subchapter S Corporation pdf None English
HCF-16036 F-16036 Self-Employment Income Worksheet - Partnership pdf None English
HCF-16037 F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business pdf None English
HCF-16038 F-16038 Administrative Disqualification Hearing Notice pdf None English
HCF-16039 F-16039 Waiver of Administrative Disqualification Hearing pdf None English
HCF-16039S F-16039S Waiver of Administrative Disqualification Hearing - Spanish pdf None Spanish
HCF-16050 F-16050 Agency Response to the State Quality Assurance (QA) FoodShare (FS) Finding pdf None English
HCF-16060 F-16060 Disaster FoodShare Wisconsin Assistance Application pdf None English
HCF-16060S F-16060S Disaster FoodShare Wisconsin Assistance Application - Spanish pdf None Spanish
HCF-16066 F-16066 FoodShare Wisconsin Income Change Report pdf Forms Center English
HCF-16066H F-16066H FoodShare Wisconsin Income Change Report - Hmong pdf None Hmong
HCF-16066R F-16066R FoodShare Wisconsin Income Change Report - Hmong pdf None Russian
HCF-16066S F-16066S FoodShare Wisconsin Income Change Report - Spanish pdf None Spanish
HCF-16073 F-16073 FoodShare Wisconsin Nonfinancial Worksheet PDF None English
HCF-16076 F-16076 FoodShare and/or Child Care Six Month Report pdf None English
HCF-16076A F-16076A FoodShare and/or Child Care Six Month Report Form Instructions PDF None English
HCF-16076AS F-16076AS FoodShare and/or Child Care Six Month Report Form Instructions - Spanish PDF None Spanish
HCF-16076S F-16076S FoodShare and/or Child Care Six Month Report - Spanish pdf None Spanish
HCF-16083 F-16083 Income Maintenance Quality Assurance (IMQA) Web Request pdf None English
HCF-16104 F-16104 Local Agency Customer Feedback PDF Forms Center English
HCF-16104S F-16104S Local Agency Customer Feedback - Spanish Paper Forms Center Spanish
HCF-16105 F-16105 Disaster FoodShare Notice pdf None English
HCF-16106 F-16106 Affidavit of Lost Income or Disaster Related Costs pdf None English
HCF-16106S F-16106S Affidavit of Lost Income or Disaster-Related Costs - Spanish pdf None Spanish

Last Revised:  July 10, 2009