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Applications and Forms

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Medicaid, BadgerCare and Family Planning Waiver Registration Application, F-10129 — Use this form to start your application process and to set your application date. You can also do this online at access.wi.gov.

Wisconsin Medicaid for the Elderly, Blind and Disabled Application/Renewal, F-10101 — Use this form to apply. You can also apply online at access.wi.gov.

Medicaid Disability Application, F-10112 — Use this form to if you need a disability determination.

Medicaid / FoodShare Wisconsin Authorization of Representative, F-10126 — Designate someone to apply for Medicaid for you.

Medicaid Change Form, F-10137 — To report changes. You can also report changes online at access.wi.gov.

Medicaid Health Insurance Information, F-10115

Request For Fair Hearing, DHA-28 (PDF, 50 KB) — To request a Fair Hearing.  (Leaving DHS)

Fair Hearing Voluntary Withdrawal, DHA-17 (PDF, 11KB) — To withdraw your Fair Hearing request. (Leaving DHS) 

BadgerCare Plus Application Packet, F- 10182

Wisconsin Circuit Courts Transfer by Affidavit ($50,000 and under) (Leaving DHS) PR-1831

ACCESS.wi.gov — Apply Online

     

Last Revised: March 27, 2014