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BadgerCare Plus Forms

Below is a list of all BadgerCare Plus forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 PDF No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets DMS English 07/2022 Word No
F-00433 Prior Authorization/Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Orally Disintegrating Tablets Instructions DMS English 07/2022 PDF No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 Word No
F-11041 Private Duty Nursing Prior Authorization Acknowledgment DMS English 10/2008 PDF No
F-02577 Proof of In-Kind Hours DMS English 06/2023 PDF No
F-02577H Proof of In-Kind Hours, Hmong DMS Hmong 06/2023 PDF No
F-02577S Proof of In-Kind Hours, Spanish DMS Spanish 06/2023 PDF No
F-00917 Provider Enrollment Application Process DMS English 12/2013 HTML No
F-11067 Record of Actual Daily Oxygen Use DMS English 07/2012 PDF No
F-11067 Record of Actual Daily Oxygen Use DMS English 07/2012 Word No
F-11067A Record of Actual Daily Oxygen Use: Completion Instructions DMS English 07/2012 PDF No
F-00233 Renewal Summary Letter DMS English 08/2019 Word No
F-00233H Renewal Summary Letter (Hmong) DMS Hmong 08/2019 Word No
F-00233S Renewal Summary Letter (Spanish) DMS Spanish 08/2019 Word No
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS English 06/2023 Word No
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS English 06/2023 PDF No
F-00107 Self-Employment Income Report DMS English 06/2019 PDF No
F-00107CM Self-Employment Income Report, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00107H Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107S Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-00219 Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
F-00219CM Self-Employment Income Report: Farm Business, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00219H Self-Employment Income Report: Farm Business, Hmong DMS Hmong 06/2019 PDF No
F-00219S Self-Employment Income Report: Farm Business, Spanish DMS Spanish 06/2019 PDF No
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS English 03/2024 PDF No
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS English 02/2017 Word No
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS English 04/2024 PDF No
F-16022 Social Security Number Referral DMS English 07/2008 PDF No
F-16022H Social Security Number Referral, Hmong DMS Hmong 07/2008 PDF No
F-16022S Social Security Number Referral, Spanish DMS Spanish 07/2008 PDF No
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS English 03/2014 PDF No
F-00885 Specialized Medical Vehicle Insurance Documentation Checklist DMS English 03/2014 Word No
F-11055 STAT-PA System Instructions DMS English 07/2015 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS English 04/2017 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS English 04/2017 Word No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request: Completion Instructions DMS English 04/2017 PDF No
F-00100 State Vital Records Birth Certificate Request Letter DMS English 06/2019 Word No
F-10161 Statement of Citizenship and/or Identity DMS English 07/2018 PDF No
F-10154 Statement of Identity for Children Under 18 Years of Age DMS English 07/2008 PDF No
F-10154DA Statement of Identity for Children Under 18 Years of Age, Dari DMS Dari (Afghan Persian) 07/2008 PDF No
F-10154H Statement of Identity for Children Under 18 Years of Age, Hmong DMS Hmong 07/2008 PDF No
F-10154PA Statement of Identity for Children Under 18 Years of Age, Pashto DMS Pashto 07/2008 PDF No
F-10154R Statement of Identity for Children Under 18 Years of Age, Russian DMS Russian 07/2008 PDF No
F-10154S Statement of Identity for Children Under 18 Years of Age, Spanish DMS Spanish 07/2008 PDF No
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS English 06/2023 PDF No
F-00685 Statement of Tribal Affiliation DMS English 06/2023 PDF No
F-00098 Summary of Information Letter DMS English 06/2019 PDF No
F-13047 Timely Filing Appeals Request and Instructions DMS English 08/2015 Word No
F-13047 Timely Filing Appeals Request and Instructions DMS English 08/2015 PDF No

Glossary

 
Last revised January 24, 2023