Skip to main content

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-10098H Medicaid Member Asset Allocation, Hmong DMS Hmong 10/2022 PDF No
F-10098S Medicaid Member Asset Allocation, Spanish DMS Spanish 10/2022 PDF No
F-10130 Medicaid Presumptive Disability DMS English 07/2024 PDF No
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS English 12/2023 PDF No
F-10127H Medicaid Purchase Plan (MAPP) - Work Requirement Exemption, Hmong DMS Hmong 12/2023 PDF No
F-10127S Medicaid Purchase Plan (MAPP) - Work Requirement Exemption, Spanish DMS Spanish 12/2023 PDF No
F-01307 Medicaid Purchase Plan (MAPP) Eligibility Worksheet DMS English 08/2020 PDF No
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS English 06/2023 PDF No
F-10121H Medicaid Purchase Plan (MAPP) Independence Account Registration, Hmong DMS Hmong 06/2023 PDF No
F-10121S Medicaid Purchase Plan (MAPP) Independence Account Registration, Spanish DMS Spanish 06/2023 PDF No
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS English 07/2008 PDF No
F-01316 Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet DMS English 08/2020 PDF No
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions DMS English 07/2008 PDF No
F-00332 Medicaid Purchase Plan Premium Information / Payment DMS English 09/2024 PDF No
F-00332S Medicaid Purchase Plan Premium Information / Payment, Spanish DMS Spanish 09/2024 PDF No
F-10106S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice, Spanish DMS Spanish 07/2008 PDF No
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DMS English 07/2008 PDF No
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice DMS English 07/2008 PDF No
F-10107S Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice, Spanish DMS Spanish 07/2008 PDF No
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS English 07/2020 HTML No
F-00855 Medication Therapy Management Case Management Software Requirements DMS English 08/2014 PDF No
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process DMS English 08/2013 PDF No
F-13023 Member / Employer Electronic Funds Transfer for Medicaid Purchase Plan Premiums DMS English 05/2024 PDF No
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-11090 Mental Health Day Treatment Functional Assessment DMS English 08/2015 Word No
F-11090 Mental Health Day Treatment Functional Assessment DMS English 08/2015 PDF No
F-11090A Mental Health Day Treatment Functional Assessment: Completion Instructions DMS English 08/2015 PDF No
F-02059 New Carrier Insurance Disclosure Onboarding DMS English 03/2017 PDF No
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS English 07/2008 PDF No
F-01165 Newborn Report DMS English 09/2019 PDF No
F-01165 Newborn Report DMS English 09/2019 Word No
F-13072 Noncompound Drug Claim DMS English 04/2017 Word No
F-13072 Noncompound Drug Claim DMS English 04/2017 PDF No
F-13072A Noncompound Drug Claim: Completion Instructions DMS English 04/2017 PDF No
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS English 07/2020 Word No
F-16015S Notice of Approval of Benefits/Positive Change in Benefits, Spanish DMS Spanish 07/2020 Word No
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS English 05/2018 Word No
F-16001AR Notice of Denial of Benefits/Negative Change in Benefits, Arabic DMS Arabic 05/2018 PDF No
F-16001CM Notice of Denial of Benefits/Negative Change in Benefits, Chinese (Simplified) DMS Chinese (Simplified) 05/2018 PDF No
F-16001G Notice of Denial of Benefits/Negative Change in Benefits, German DMS German 05/2018 PDF No
F-16001H Notice of Denial of Benefits/Negative Change in Benefits, Hmong DMS Hmong 05/2018 PDF No
F-16001L Notice of Denial of Benefits/Negative Change in Benefits, Laotian DMS Laotian 05/2018 PDF No
F-16001R Notice of Denial of Benefits/Negative Change in Benefits, Russian DMS Russian 05/2018 PDF No
F-16001SO Notice of Denial of Benefits/Negative Change in Benefits, Somali DMS Somali 05/2018 PDF No
F-16001S Notice of Denial of Benefits/Negative Change in Benefits, Spanish DMS Spanish 05/2018 Word No
F-13038 Notice of Intent to File a Lien (Paper Only. Follow link to order paper copy.) DMS English 06/2010 Paper Only Yes
F-16014 Notice of Program Violation DMS English 03/2018 PDF No
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS English 07/2008 PDF No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request DMS English 11/2018 Word No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request DMS English 11/2018 PDF No

Glossary

 
Last revised January 24, 2023