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Eligibility Management (Income Maintenance) Home >> IM Forms

BadgerCare Plus Forms Sorted by Language

Last Revised: March 26, 2014

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 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 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, 2417 KB) F-10182 Paper 4/1/2014
English BadgerCare Plus Change Report (PDF, 345 KB) F-10183 Paper 11/1/2013
English BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication F-10185 Word 7/1/2008
English BadgerCare Plus Express Enrollment for Pregnant Women Application F-10081 Paper 2/1/2014
English BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 100 KB) F-10081A PDF 3/1/2014
English BadgerCare Plus Premium Employer Wage Withholding (PDF, 92 KB) F-13025 PDF 9/1/2013
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, 202 KB) F-13026 PDF 5/1/2014
English BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) F-10138 PDF 7/1/2008
English BadgerCare Plus Tax Filer Information (PDF, 238 KB) F-00914 PDF 12/1/2013
English BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) F-00914A PDF 12/1/2013
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 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 6/1/2014
English Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) F-10111 PDF 9/1/2013
English Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) F-10111A PDF 9/1/2013
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 Paper 11/1/2009
English Local Agency Customer Feedback (PDF, 17 KB) F-16104H PDF 11/1/2009
English Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 PDF 2/1/2013
English Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) F-10129 PDF 9/1/2013
English Medicaid / BadgerCare Plus Certification F-10110 System 4/1/2011
English Medicaid / BadgerCare Plus Certification Instructions F-10110A System 4/1/2011
English Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) F-10151 PDF 7/1/2008
English Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) F-10109 PDF 2/1/2014
English Medicaid and BadgerCare Plus Overpayment Notice F-10093 Word 9/1/2013
English Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) F-10093 PDF 9/1/2013
English Medicaid and BadgerCare Plus Overpayment Notice - Spanish F-10093S Word 9/1/2013
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, 91 KB) F-00107 PDF 5/1/2013
English Self-Employment Income Report (Worksheet) (PDF, 32 KB) F-00107W PDF 5/1/2010
English Self-Employment Income Report - Farmer (PDF, 74 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, 25 KB) F-16034 PDF 2/1/2014
English Self-Employment Income Worksheet - Partnership (PDF, 27 KB) F-16036 PDF 2/1/2014
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) F-16037 PDF 2/1/2014
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) F-16037A PDF 6/1/2014
English Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) F-16035 PDF 2/1/2014
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, 36 KB) F-10175 PDF 9/1/2013
English Statement of Tribal Affiliation (PDF, 24 KB) F-00685 PDF 11/1/2012
English Summary of Information Letter (PDF, 224 KB) F-00098 PDF 6/1/2009
English Verification of Veterans Benefits (PDF, 53 KB) F-10162 PDF 1/1/2014
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) F-10143 PDF 11/1/2013
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) F-10141 PDF 11/1/2013
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 - Spanish (PDF, 56 KB) F-10150AS PDF 10/1/2012
English Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 PDF 9/1/2013
Hmong BadgerCare Plus Application Packet - Hmong (PDF, 1310 KB) F-10182H PDF 4/1/2014
Hmong BadgerCare Plus Change Report - Hmong (PDF, 284 KB) F-10183H PDF 11/1/2013
Hmong Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H PDF 2/1/2013
Hmong Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) F-10129H PDF 9/1/2013
Hmong Renewal Summary Letter (Hmong) F-00233H Word 4/1/2010
Hmong Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) F-00219H PDF 6/1/2013
Hmong Self-Employment Income Report - Hmong (PDF, 51 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, 1460 KB) F-10182S PDF 4/1/2014
Spanish BadgerCare Plus Change Report - Spanish (PDF, 340 KB) F-10183S PDF 11/1/2013
Spanish BadgerCare Plus Premium Information / Payment - Spanish (PDF, 37 KB) F-10139S PDF 7/1/2012
Spanish BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) F-00914S PDF 12/1/2013
Spanish Local Agency Customer Feedback - Spanish (PDF, 16 KB) F-16104S Paper 11/1/2009
Spanish Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S PDF 2/1/2013
Spanish Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) F-10093S PDF 9/1/2013
Spanish Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) F-10129S PDF 9/1/2013
Spanish Negative Notice - Spanish F-16001S Word 7/1/2008
Spanish Negative Notice - Spanish (PDF, 74 KB) F-16001S PDF 7/1/2008
Spanish Positive Notice - Spanish F-16015S Word 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, 77 KB) F-00219S PDF 6/1/2013
Spanish Self-Employment Income Report - Spanish (PDF, 52 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
Spanish Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) F-10150S PDF 9/1/2013