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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-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age), Spanish DMS Spanish 07/2008 Word No
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS English 07/2008 PDF No
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age DMS English 07/2008 Word No
F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age, Spanish DMS Spanish 07/2008 Word No
F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age, Spanish DMS Spanish 07/2008 PDF No
F-01063 HealthCheck Family History DMS English 08/2017 PDF No
F-01063 HealthCheck Family History DMS English 08/2017 Word No
F-01063S HealthCheck Family History, Spanish DMS Spanish 08/2017 PDF No
F-01063S HealthCheck Family History, Spanish DMS Spanish 08/2017 Word No
F-01002 HealthCheck Individual Health History DMS English 08/2019 PDF No
F-01002 HealthCheck Individual Health History DMS English 08/2019 Word No
F-01002H HealthCheck Individual Health History, Hmong DMS Hmong 08/2019 PDF No
F-01002H HealthCheck Individual Health History, Hmong DMS Hmong 08/2019 Word No
F-01002S HealthCheck Individual Health History, Spanish DMS Spanish 08/2019 PDF No
F-01002S HealthCheck Individual Health History, Spanish DMS Spanish 08/2019 Word No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS English 07/2008 PDF No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS English 07/2008 Word No
F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age), Spanish DMS Spanish 07/2008 Word No
F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age), Spanish DMS Spanish 07/2008 PDF No
F-00021 HealthCheck Referral DMS English 01/2017 PDF No
F-01067 HealthCheck Your Child's Speech and Hearing DMS English 07/2008 PDF No
F-01067 HealthCheck Your Child's Speech and Hearing DMS English 07/2008 Word No
F-01359 Historical Earnings Verification Request DMS English 02/2022 Word No
F-03112 HMO Quarterly Appeals Log DMS English 05/2024 Excel No
F-03112A HMO Quarterly Grievance Log DMS English 08/2024 Excel No
F-03112AI HMO Quarterly Grievance Log Instructions DMS English 01/2024 PDF No
F-10183 Information Change Report DMS English 05/2017 PDF No
F-10183DA Information Change Report, Dari DMS Dari (Afghan Persian) 05/2017 PDF No
F-10183H Information Change Report, Hmong DMS Hmong 05/2017 PDF No
F-10183PA Information Change Report, Pashto DMS Pashto 05/2017 PDF No
F-10183S Information Change Report, Spanish DMS Spanish 05/2017 PDF No
F-03112I Instructions for Logging HMO Appeals DMS English 01/2024 PDF No
F-00107 Instructions, Self-Employment Income Report DMS English 06/2019 PDF No
F-00107ACM Instructions, Self-Employment Income Report, Chinese (Simplified) DMS Chinese (Simplified) 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-01234A Instructions: Explanation of Medical Benefits DMS English 11/2023 PDF No
F-10110A Instructions: Medicaid/BadgerCare Plus Eligibility Certification DMS English 01/2018 HTML No
F-11010A Instructions: Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS English 01/2018 PDF No
F-11008A Instructions: Prior Authorization / Therapy Attachment (PA/TA) DMS English 07/2024 PDF No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 Word No
F-12022A Managed Care Program Provider Appeal Instructions DMS English 02/2020 PDF No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS English 06/2018 PDF No
F-10151H Medicaid / BadgerCare Plus Fair Hearing Information, Hmong DMS Hmong 06/2018 PDF No
F-10151S Medicaid / BadgerCare Plus Fair Hearing Information, Spanish DMS Spanish 06/2018 PDF No

Glossary

 
Last revised January 24, 2023