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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

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

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

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 — Apply Online


Last Revised: March 27, 2014