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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 File Type Available to Order
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 05/2024 Excel No
F-03112AI HMO Quarterly Grievance Log Instructions DMS English 01/2024 PDF No
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program DMS English 06/2023 PDF No
F-22541 Incident Report - IRIS DMS English 07/2020 PDF No
F-22541 Incident Report - IRIS DMS English 07/2020 Word No
F-20445 Individual Service Plan - Children’s Long-Term Support Programs DMS English 09/2022 PDF No
F-20445 Individual Service Plan - Children’s Long-Term Support Programs DMS English 09/2022 Word No
F-20445H Individual Service Plan - Children’s Long-Term Support Programs, Hmong DMS Hmong 09/2022 PDF No
F-20445H Individual Service Plan - Children’s Long-Term Support Programs, Hmong DMS Hmong 09/2022 Word No
F-20445I Individual Service Plan - Children’s Long-Term Support Programs, Instructions DMS English 09/2022 PDF No
F-20445S Individual Service Plan - Children’s Long-Term Support Programs, Spanish DMS Spanish 09/2022 Word No
F-20445S Individual Service Plan - Children’s Long-Term Support Programs, Spanish DMS Spanish 09/2022 PDF No
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS English 05/2022 Word No
F-20445A Individual Service Plan: Outcomes, Children’s Long-Term Support Programs DMS English 05/2022 PDF No
F-20445AH Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Hmong DMS Hmong 05/2022 PDF No
F-20445AH Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Hmong DMS Hmong 05/2022 Word No
F-20445AS Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Spanish DMS Spanish 05/2022 Word No
F-20445AS Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Spanish DMS Spanish 05/2022 PDF No
F-10097 Institutional Medicaid Income Allocation DMS English 04/2024 PDF No
F-10097H Institutional Medicaid Income Allocation, Hmong DMS Hmong 04/2024 PDF No
F-10097S Institutional Medicaid Income Allocation, Spanish DMS Spanish 04/2024 PDF No
F-00286 Instructions DMS English 07/2015 PDF No
F-00556 Instructions DMS English 01/2018 PDF No
F-11040A Instructions DMS English 12/2019 PDF No
F-11079 Instructions DMS English 07/2017 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-11133A Instructions: Personal Care Screening Tool (PCST) DMS English 08/2017 PDF 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 05/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
F-00219ACM Instructions: Self-Employment Income Report: Farm Business, Chinese (Simplified) DMS Chinese (Simplified) 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Hmong DMS Hmong 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Spanish DMS Spanish 06/2019 PDF No
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS English 07/2008 PDF No
F-03102 Katie Beckett Disability Evaluation Form DMS English 11/2022 Word No
F-03102 Katie Beckett Disability Evaluation Form DMS English 11/2022 PDF No
F-01661A Letter - Foster Care Termination, Youth DMS English 11/2023 Word No
F-01567A Letter: Request for Assignment of Medical Benefits DMS English 01/2021 Word 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-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 PDF No

Glossary

 
Last revised January 24, 2023