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Medicaid Forms

Below is a list of all Medicaid 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 Available to order
F-01161 Abortion Certification Statements (Word) DMS English 09/2019 No
F-01161 Abortion Certification Statements (PDF) DMS English 09/2019 No
F-01160 Acknowledgement of Receipt of Hysterectomy Information (Word) DMS English 06/2013 No
F-01160 Acknowledgement of Receipt of Hysterectomy Information (PDF) DMS English 06/2013 No
F-01160A Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF) DMS English 06/2013 No
F-01160AH Acknowledgement of Receipt of Hysterectomy Information Completion Instructions, Hmong (PDF) DMS Hmong 06/2013 No
F-01160AS Acknowledgement of Receipt of Hysterectomy Information Completion Instructions, Spanish (PDF) DMS Spanish 06/2013 No
F-01160H Acknowledgement of Receipt of Hysterectomy Information, Hmong (Word) DMS Hmong 06/2013 No
F-01160H Acknowledgement of Receipt of Hysterectomy Information, Hmong (PDF) DMS Hmong 06/2013 No
F-01160S Acknowledgement of Receipt of Hysterectomy Information, Spanish (PDF) DMS Spanish 06/2013 No
F-01160S Acknowledgement of Receipt of Hysterectomy Information, Spanish (Word) DMS Spanish 06/2013 No
F-13046 Adjustment / Reconsideration Request (Word) DMS English 02/2025 No
F-13046 Adjustment / Reconsideration Request (PDF) DMS English 02/2025 No
F-13046A Adjustment / Reconsideration Request: Completion Instructions (PDF) DMS English 02/2025 No
F-03250 Adult Long-Term Care (LTC) Waiver Provider Application Information and Instructions (Word) DMS English 04/2026 No
F-03250 Adult Long-Term Care (LTC) Waiver Provider Application Information and Instructions (PDF) DMS English 04/2026 No
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF) DMS English 07/2008 No
F-10126B Appoint, Change, or Remove an Authorized Representative: Organization (PDF) DMS English 06/2026 No
F-10126BAR Appoint, Change, or Remove an Authorized Representative: Organization, Arabic (PDF) DMS Arabic 06/2026 No
F-10126BCM Appoint, Change, or Remove an Authorized Representative: Organization, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 06/2026 No
F-10126BDA Appoint, Change, or Remove an Authorized Representative: Organization, Dari (PDF) DMS Dari (Afghan Persian) 06/2026 No
F-10126BG Appoint, Change, or Remove an Authorized Representative: Organization, German (PDF) DMS German 06/2026 No
F-10126BH Appoint, Change, or Remove an Authorized Representative: Organization, Hmong (PDF) DMS Hmong 06/2026 No
F-10126BL Appoint, Change, or Remove an Authorized Representative: Organization, Laotian (PDF) DMS Lao 06/2026 No
F-10126BPA Appoint, Change, or Remove an Authorized Representative: Organization, Pashto (PDF) DMS Pashto 06/2026 No
F-10126BR Appoint, Change, or Remove an Authorized Representative: Organization, Russian (PDF) DMS Russian 06/2026 No
F-10126BSO Appoint, Change, or Remove an Authorized Representative: Organization, Somali (PDF) DMS Somali 06/2026 No
F-10126BS Appoint, Change, or Remove an Authorized Representative: Organization, Spanish (PDF) DMS Spanish 06/2026 No
F-10126A Appoint, Change, or Remove an Authorized Representative: Person (PDF) DMS English 06/2026 No
F-10126AAR Appoint, Change, or Remove an Authorized Representative: Person, Arabic (PDF) DMS Arabic 06/2026 No
F-10126ACM Appoint, Change, or Remove an Authorized Representative: Person, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 06/2026 No
F-10126ADA Appoint, Change, or Remove an Authorized Representative: Person, Dari (PDF) DMS Dari (Afghan Persian) 06/2026 No
F-10126AG Appoint, Change, or Remove an Authorized Representative: Person, German (PDF) DMS German 06/2026 No
F-10126AH Appoint, Change, or Remove an Authorized Representative: Person, Hmong (PDF) DMS Hmong 06/2026 No
F-10126AL Appoint, Change, or Remove an Authorized Representative: Person, Laotian (PDF) DMS Lao 06/2026 No
F-10126APA Appoint, Change, or Remove an Authorized Representative: Person, Pashto (PDF) DMS Pashto 06/2026 No
F-10126ARY Appoint, Change, or Remove an Authorized Representative: Person, Rohingya (PDF) DMS Rohingya 06/2026 No
F-10126AR Appoint, Change, or Remove an Authorized Representative: Person, Russian (PDF) DMS Russian 06/2026 No
F-10126ASO Appoint, Change, or Remove an Authorized Representative: Person, Somali (PDF) DMS Somali 06/2026 No
F-10126AS Appoint, Change, or Remove an Authorized Representative: Person, Spanish (PDF) DMS Spanish 06/2026 No
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections (Word) DMS English 04/2014 No
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections (PDF) DMS English 04/2014 No
F-00286A Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Completion Instructions (PDF) DMS English 07/2015 No
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF) DMS English 03/2022 No
F-14014H Authorization to Disclose Information to Disability Determination Bureau (DDB), Hmong (PDF) DMS Hmong 03/2022 No
F-14014S Authorization to Disclose Information to Disability Determination Bureau (DDB), Spanish (PDF) DMS Spanish 03/2022 No
F-00101 Authorization to Request Birth Records (Word) DMS English 06/2019 No
F-10115 BadgerCare Plus / Medicaid Health Insurance Information (PDF) DMS English 01/2011 No
F-10115S BadgerCare Plus / Medicaid Health Insurance Information, Spanish (PDF) DMS Spanish 01/2011 No
F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification (PDF) OIG English 01/2021 No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised September 30, 2025