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Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: July 12, 2010

This list contains BadgerCare Plus forms that are available from DHCAA sorted by the language in which they are written. 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.

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