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Eligibility Management (Income Maintenance) Home >> IM Forms

BadgerCare Plus Forms Sorted by Form Type

Last Revised: March 26, 2014

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 Application Packet (PDF, 2417 KB) F-10182 4/1/2014 English
Paper BadgerCare Plus Change Report (PDF, 345 KB) F-10183 11/1/2013 English
Paper BadgerCare Plus Express Enrollment for Pregnant Women Application F-10081 2/1/2014 English
Paper Local Agency Customer Feedback (PDF, 129 KB) F-16104 8/1/2014 English
Paper Local Agency Customer Feedback - Spanish (PDF, 29 KB) F-16104S 8/1/2014 Spanish
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 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 - Hmong (PDF, 1310 KB) F-10182H 4/1/2014 Hmong
PDF BadgerCare Plus Application Packet - Spanish (PDF, 1460 KB) F-10182S 4/1/2014 Spanish
PDF BadgerCare Plus Change Report - Hmong (PDF, 284 KB) F-10183H 11/1/2013 Hmong
PDF BadgerCare Plus Change Report - Spanish (PDF, 340 KB) F-10183S 11/1/2013 Spanish
PDF BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 100 KB) F-10081A 3/1/2014 English
PDF BadgerCare Plus Premium Employer Wage Withholding (PDF, 92 KB) F-13025 9/1/2013 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, 202 KB) F-13026 5/1/2014 English
PDF BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) F-10138 7/1/2008 English
PDF BadgerCare Plus Tax Filer Information (PDF, 238 KB) F-00914 12/1/2013 English
PDF BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) F-00914S 12/1/2013 Spanish
PDF BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) F-00914A 12/1/2013 English
PDF Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) F-00628 7/1/2012 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, 32 KB) F-10111 9/1/2013 English
PDF Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) F-10111A 9/1/2013 English
PDF Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 8/1/2011 English
PDF Local Agency Customer Feedback (Hmong) (PDF, 55 KB) F-16104H 8/1/2014 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 2/1/2013 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H 2/1/2013 Hmong
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S 2/1/2013 Spanish
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) F-10129 9/1/2013 English
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) F-10129H 9/1/2013 Hmong
PDF Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) F-10151 7/1/2008 English
PDF Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) F-10109 2/1/2014 English
PDF Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) F-10093S 9/1/2013 Spanish
PDF Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) F-10093 9/1/2013 English
PDF Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) F-10129S 9/1/2013 Spanish
PDF Negative Notice (PDF, 154 KB) F-16001 7/1/2008 English
PDF Negative Notice - Spanish (PDF, 74 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, 91 KB) F-00107 5/1/2013 English
PDF Self-Employment Income Report (Worksheet) (PDF, 37 KB) F-00107W 6/1/2014 English
PDF Self-Employment Income Report - Farmer (PDF, 74 KB) F-00219 6/1/2013 English
PDF Self-Employment Income Report - Farmer (Worksheet) (PDF, 37 KB) F-00219W 6/1/2014 English
PDF Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) F-00219H 6/1/2013 Hmong
PDF Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S 6/1/2013 Spanish
PDF Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H 4/1/2013 Hmong
PDF Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S 4/1/2013 Spanish
PDF Self-Employment Income Worksheet - Corporation (PDF, 25 KB) F-16034 2/1/2014 English
PDF Self-Employment Income Worksheet - Partnership (PDF, 27 KB) F-16036 2/1/2014 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) F-16037 2/1/2014 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) F-16037A 6/1/2014 English
PDF Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) F-16035 2/1/2014 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, 36 KB) F-10175 9/1/2013 English
PDF Statement of Tribal Affiliation (PDF, 24 KB) F-00685 11/1/2012 English
PDF Summary of Information Letter (PDF, 224 KB) F-00098 6/1/2009 English
PDF Verification of Veterans Benefits (PDF, 53 KB) F-10162 1/1/2014 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) F-10143 11/1/2013 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) F-10141 11/1/2013 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 - Spanish (PDF, 56 KB) F-10150AS 10/1/2012 English
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) F-10150S 9/1/2013 Spanish
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 9/1/2013 English
System Medicaid / BadgerCare Plus Certification F-10110 4/1/2011 English
System Medicaid / BadgerCare Plus Certification Instructions F-10110A 4/1/2011 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 Former Foster Care Youth (FFCY) F-10184 11/1/2014 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 9/1/2014 English
Word Historical Earnings Verification Request F-01359 9/1/2014 English
Word Life Insurance Inquiry F-10144 7/1/2008 English
Word Medicaid and BadgerCare Plus Overpayment Notice F-10093 9/1/2013 English
Word Medicaid and BadgerCare Plus Overpayment Notice - Spanish F-10093S 9/1/2013 English
Word Negative Notice F-16001 7/1/2008 English
Word Negative Notice - Spanish F-16001S 7/1/2008 Spanish
Word Positive Notice F-16015 7/1/2008 English
Word Positive Notice - Spanish F-16015S 7/1/2008 Spanish
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