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Family Planning Only Services




Caretaker Supplement

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Eligibility Management (Income Maintenance) Home >> Customer Help >> Medicaid Help 

Customer Help - Medicaid

To see if you may be able to enroll or to apply, go to


Application F-10101 (English, Hmong, Spanish) (PDF, 268KB) To apply apply for Medicaid or you can apply online at

Authorization of Representative F-10126 (English, Hmong, Spanish) (PDF, 453KB)  Designate someone to apply for Medicaid for you.

Change Report F-10137 (English, Hmong, Spanish) (PDF, 544KB)  Report changes to the local agency or you can report changes online at

Disability Application F-10112 (English, Spanish) (PDF, 234KB) Use this application along with the F-10101 if you need a disability determination.

Fair Hearing Request (exit DHS) - To request a hearing if you don't agree with a decision about your benefits.

Fair Hearing Voluntary Withdrawal DHA 17, (PDF 10KB) *(exit DHS) If you want to withdraw your request for a hearing.

Self-Employment Income Report (SEIRF) form F-00107, (English, Hmong, Spanish) (PDF  KB) Use this form to report self-employment income.

Statement of Identity F-10154  (English, Hmong, Russian, Spanish), (PDF, 91KB) To provide proof of identity for children under 18 years of age.


ForwardHealth Enrollment and Benefits Handbook - July 2014
(English) (PDF 2.6 MB)
ForwardHealth Enrollment and Benefits Handbook - November 2013
(English, Spanish) (PDF 3.3 MB)
A handbook will be mailed to each family who applies for a ForwardHealth Plan.

Guide to Applying for Wisconsin's Health and Nutrition Programs P-16091 (English, Hmong, Spanish) (PDF, 181KB)

ACCESS/Marketplace Takeaway Card, P-00555 - (English, Spanish) (PDF, 549KB)

Healthy Start, Grow Smart: Baby's first year one month at a time

Additional Links  

Additional Information about Medicaid can be found at

Agency Directory - To find the telephone number and address of your local agency.

Contact a Disability Benefit Specialist or Benefit Specialist at your local Aging and Disability Resource Center (ADRC) or County Aging Office or call 1-800-362-3002.

Find a provider If you need to find a Medicaid provider in your area.

Income Limits - To find current income limits.

Legal Services To find the name and telephone number of who in your area can provide you with legal help.  You may also go to:  

Disability Rights of Wisconsin Disability Rights Wisconsin is a private non profit organization which helps people across Wisconsin gain access to services and opportunity through its advocacy and legal expertise.*(exit DHS)

Last Revised: September 15, 2014