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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
BadgerCare Plus Forms Sorted by Form Type

Last Revised: July 12, 2010

This list contains BadgerCare Plus forms that are available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). Forms marked as "PDF-Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Type Form Title Form Number Revised Date Language Text
Paper BadgerCare Plus Express Enrollment for Pregnant Women Application F-10081 10/1/2008 English
PDF Administrative Disqualification Hearing Notice (PDF, 81 KB) F-16038 10/1/2011 English
PDF Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) F-10171 7/1/2008 English
PDF Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) F-10172 7/1/2008 English
PDF Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children (PDF, 120 KB) F-10148 7/1/2012 English
PDF Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women (PDF, 132 KB) F-10177 7/1/2012 English
PDF BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) F-10115 1/1/2011 English
PDF BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) F-10115S 1/1/2011 Spanish
PDF BadgerCare Plus Application Packet (PDF, 878 KB) F-10182 9/1/2012 English
PDF BadgerCare Plus Application Packet - Hmong (PDF, 1.7 MB) F-10182H 7/1/2008 Hmong
PDF BadgerCare Plus Application Packet - Spanish (PDF, 819 KB) F-10182S 10/1/2008 Spanish
PDF BadgerCare Plus Change Report (PDF, 299 KB) F-10183 7/1/2008 English
PDF BadgerCare Plus Change Report - Hmong (PDF, 307 KB) F-10183H 7/1/2008 Hmong
PDF BadgerCare Plus Change Report - Spanish (PDF, 307 KB) F-10183S 7/1/2008 Spanish
PDF BadgerCare Plus Core Plan Non-Refundable Processing Fee Payment (PDF, 46 KB) F-00623 6/1/2012 English
PDF BadgerCare Plus Core Plan Non-Refundable Processing Fee Payment - Spanish (PDF, 42 KB) F-00623S 6/1/2012 Spanish
PDF BadgerCare Plus Express Enrollment Change Request for Partners / Providers (PDF, 96 KB) F-10176 7/1/2012 English
PDF BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 44 KB) F-10081A 10/1/2008 English
PDF BadgerCare Plus Premium Employer Wage Withholding (PDF, 72 KB) F-13025 7/1/2008 English
PDF BadgerCare Plus Premium Information / Payment (PDF, 76 KB) F-10139 7/1/2012 English
PDF BadgerCare Plus Premium Information / Payment - Spanish (PDF, 37 KB) F-10139S 7/1/2012 Spanish
PDF BadgerCare Plus Premium Member / Employer Electronic Funds Transfer (PDF, 91 KB) F-13026 7/1/2008 English
PDF BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) F-10138 7/1/2008 English
PDF Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) F-00628 7/1/2012 English
PDF Designation of a BadgerCare Plus Essential Person (PDF, 110 KB) F-10186 7/1/2008 English
PDF Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) F-00246 7/1/2012 English
PDF Good Faith Medicaid / BadgerCare Plus Certification (PDF, 40 KB) F-10111 2/1/2009 English
PDF Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 18 KB) F-10111A 2/1/2009 English
PDF Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 8/1/2011 English
PDF Local Agency Customer Feedback (PDF, 17 KB) F-16104 11/1/2009 English
PDF Local Agency Customer Feedback - Spanish (PDF, 16 KB) F-16104S 11/1/2009 Spanish
PDF Medicaid / BadgerCare Overpayment Notice - Spanish (PDF, 31 KB) F-10093S 7/1/2008 Spanish
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 192 KB) F-10126 2/1/2013 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 242 KB) F-10126H 7/1/2008 Hmong
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 529 KB) F-10126S 7/1/2008 Spanish
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 46 KB) F-10129 6/1/2009 English
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 32 KB) F-10129H 6/1/2009 Hmong
PDF Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) F-10151 7/1/2008 English
PDF Medicaid / BadgerCare Plus Overpayment Notice (PDF, 364 KB) F-10093 7/1/2008 English
PDF Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 33 KB) F-10129S 6/1/2009 Spanish
PDF Negative Notice (PDF, 154 KB) F-16001 7/1/2008 English
PDF Negative Notice - Spanish (PDF, 200 KB) F-16001S 7/1/2008 Spanish
PDF New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) F-10180 7/1/2008 English
PDF Notice of Program Violation (PDF, 43 KB) F-16014 7/1/2008 English
PDF Positive Notice (PDF, 134 KB) F-16015 7/1/2008 English
PDF Positive Notice - Spanish (PDF, 46 KB) F-16015S 7/1/2008 Spanish
PDF Self-Employment Income Report (PDF, 38 KB) F-00107 4/1/2013 English
PDF Self-Employment Income Report (Worksheet) (PDF, 31 KB) F-00107W 5/1/2010 English
PDF Self-Employment Income Report - Farmer (PDF, 80 KB) F-00219 5/1/2010 English
PDF Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) F-00219W 5/1/2010 English
PDF Self-Employment Income Report - Farmer - Hmong (PDF, 69 KB) F-00219H 5/1/2010 Hmong
PDF Self-Employment Income Report - Farmer - Spanish (PDF, 81 KB) F-00219S 5/1/2010 Spanish
PDF Self-Employment Income Report - Hmong (PDF, 29 KB) F-00107H 4/1/2013 Hmong
PDF Self-Employment Income Report - Spanish (PDF, 29 KB) F-00107S 4/1/2013 Spanish
PDF Self-Employment Income Worksheet - Corporation (PDF, 37 KB) F-16034 2/1/2010 English
PDF Self-Employment Income Worksheet - Partnership (PDF, 49 KB) F-16036 9/1/2012 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 72 KB) F-16037 9/1/2012 English
PDF Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 60 KB) F-16035 5/1/2009 English
PDF Social Security Number Referral (PDF, 61 KB) F-16022 7/1/2008 English
PDF Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H 7/1/2008 Hmong
PDF Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S 7/1/2008 Spanish
PDF Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) F-10161 7/1/2008 English
PDF Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) F-10154 7/1/2008 English
PDF Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) F-10154H 7/1/2008 Hmong
PDF Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) F-10154R 7/1/2008 Russian
PDF Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) F-10154S 7/1/2008 Spanish
PDF Statement of Identity for Persons in Institutional Care Facilities (PDF, 102 KB) F-10175 7/1/2008 English
PDF Statement of Tribal Affiliation (PDF, 24 KB) F-00685 11/1/2012 English
PDF Verification of Veterans Benefits (PDF, 136 KB) F-10162 7/1/2008 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 41 KB) F-10143 1/1/2011 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 84 KB) F-10141 1/1/2011 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions (PDF, 20 KB) F-10141A 1/1/2011 English
PDF Your Rights and Responsibilities for Health Care (PDF, 56 KB) F-10150A 10/1/2012 English
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 79 KB) F-10150 10/1/2012 English
System Medicaid / BadgerCare Plus Certification F-10110 11/1/2008 English
Word Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children F-10148 7/1/2012 English
Word Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women F-10177 7/1/2012 English
Word Authorization to Request Birth Records F-00101 6/1/2009 English
Word BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication F-10185 7/1/2008 English
Word BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 7/1/2012 English
Word BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) F-10184 7/1/2008 English
Word Consortium Response to the State IM Second Party Review Finding F-00628 7/1/2012 English
Word Employment Verification of Earnings F-10146 7/1/2008 English
Word Life Insurance Inquiry F-10144 7/1/2008 English
Word Negative Notice F-16001 7/1/2008 English
Word Positive Notice F-16015 7/1/2008 English
Word Renewal Summary Letter F-00233 4/1/2010 English
Word Renewal Summary Letter (Hmong) F-00233H 4/1/2010 Hmong
Word Renewal Summary Letter (Spanish) F-00233S 4/1/2010 Spanish
Word State Vital Records Cover Letter F-00100 6/1/2009 English
Word Summary of Information Letter F-00098 6/1/2009 English