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Eligibility Management (Income Maintenance) Home >> IM Forms

BadgerCare Plus Forms Sorted by Form Number

Last Revised: March 26, 2014

This list contains BadgerCare Plus forms that are available from DHCAA. 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  Number Form Title Form Type Revised Date Language
F-00098 Summary of Information Letter (PDF, 224 KB) PDF 6/1/2009 English
F-00100 State Vital Records Cover Letter Word 6/1/2009 English
F-00101 Authorization to Request Birth Records Word 6/1/2009 English
F-00107 Self-Employment Income Report (PDF, 91 KB) PDF 5/1/2013 English
F-00107H Self-Employment Income Report - Hmong (PDF, 51 KB) PDF 4/1/2013 Hmong
F-00107S Self-Employment Income Report - Spanish (PDF, 52 KB) PDF 4/1/2013 Spanish
F-00107W Self-Employment Income Report (Worksheet) (PDF, 32 KB) PDF 5/1/2010 English
F-00219 Self-Employment Income Report - Farmer (PDF, 74 KB) PDF 6/1/2013 English
F-00219H Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) PDF 6/1/2013 Hmong
F-00219S Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) PDF 6/1/2013 Spanish
F-00219W Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) PDF 5/1/2010 English
F-00233 Renewal Summary Letter Word 4/1/2010 English
F-00233H Renewal Summary Letter (Hmong) Word 4/1/2010 Hmong
F-00233S Renewal Summary Letter (Spanish) Word 4/1/2010 Spanish
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) PDF 7/1/2012 English
F-00628 Consortium Response to the State IM Second Party Review Finding Word 7/1/2012 English
F-00628 Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) PDF 7/1/2012 English
F-00685 Statement of Tribal Affiliation (PDF, 24 KB) PDF 11/1/2012 English
F-00914 BadgerCare Plus Tax Filer Information (PDF, 238 KB) PDF 12/1/2013 English
F-00914A BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) PDF 12/1/2013 English
F-00914S BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) PDF 12/1/2013 Spanish
F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application Paper 2/1/2014 English
F-10081A BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 100 KB) PDF 3/1/2014 English
F-10093 Medicaid and BadgerCare Plus Overpayment Notice Word 9/1/2013 English
F-10093 Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) PDF 9/1/2013 English
F-10093S Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) PDF 9/1/2013 Spanish
F-10093S Medicaid and BadgerCare Plus Overpayment Notice - Spanish Word 9/1/2013 English
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) PDF 2/1/2014 English
F-10110 Medicaid / BadgerCare Plus Certification System 4/1/2011 English
F-10110A Medicaid / BadgerCare Plus Certification Instructions System 4/1/2011 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) PDF 9/1/2013 English
F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) PDF 9/1/2013 English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) PDF 1/1/2011 English
F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) PDF 1/1/2011 Spanish
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) PDF 2/1/2013 English
F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) PDF 2/1/2013 Hmong
F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) PDF 2/1/2013 Spanish
F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) PDF 9/1/2013 English
F-10129H Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) PDF 9/1/2013 Hmong
F-10129S Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) PDF 9/1/2013 Spanish
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) PDF 7/1/2008 English
F-10139 BadgerCare Plus Premium Information / Payment (PDF, 76 KB) PDF 7/1/2012 English
F-10139S BadgerCare Plus Premium Information / Payment - Spanish (PDF, 37 KB) PDF 7/1/2012 Spanish
F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) PDF 11/1/2013 English
F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) PDF 11/1/2013 English
F-10144 Life Insurance Inquiry Word 7/1/2008 English
F-10146 Employment Verification of Earnings Word 6/1/2014 English
F-10150 Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) PDF 9/1/2013 English
F-10150A Your Rights and Responsibilities for Health Care (PDF, 56 KB) PDF 10/1/2012 English
F-10150AS Your Rights and Responsibilities for Health Care - Spanish (PDF, 56 KB) PDF 10/1/2012 English
F-10150S Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) PDF 9/1/2013 Spanish
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) PDF 7/1/2008 English
F-10154 Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) PDF 7/1/2008 English
F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) PDF 7/1/2008 Hmong
F-10154R Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) PDF 7/1/2008 Russian
F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) PDF 7/1/2008 Spanish
F-10161 Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) PDF 7/1/2008 English
F-10162 Verification of Veterans Benefits (PDF, 53 KB) PDF 1/1/2014 English
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) PDF 7/1/2008 English
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) PDF 7/1/2008 English
F-10175 Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) PDF 9/1/2013 English
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) PDF 7/1/2008 English
F-10182 BadgerCare Plus Application Packet (PDF, 2417 KB) Paper 4/1/2014 English
F-10182H BadgerCare Plus Application Packet - Hmong (PDF, 1310 KB) PDF 4/1/2014 Hmong
F-10182S BadgerCare Plus Application Packet - Spanish (PDF, 1460 KB) PDF 4/1/2014 Spanish
F-10183 BadgerCare Plus Change Report (PDF, 345 KB) Paper 11/1/2013 English
F-10183H BadgerCare Plus Change Report - Hmong (PDF, 284 KB) PDF 11/1/2013 Hmong
F-10183S BadgerCare Plus Change Report - Spanish (PDF, 340 KB) PDF 11/1/2013 Spanish
F-10184 BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) Word 7/1/2008 English
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication Word 7/1/2008 English
F-13025 BadgerCare Plus Premium Employer Wage Withholding (PDF, 92 KB) PDF 9/1/2013 English
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer (PDF, 202 KB) PDF 5/1/2014 English
F-16001 Negative Notice Word 7/1/2008 English
F-16001 Negative Notice (PDF, 154 KB) PDF 7/1/2008 English
F-16001S Negative Notice - Spanish Word 7/1/2008 Spanish
F-16001S Negative Notice - Spanish (PDF, 74 KB) PDF 7/1/2008 Spanish
F-16014 Notice of Program Violation (PDF, 43 KB) PDF 7/1/2008 English
F-16015 Positive Notice Word 7/1/2008 English
F-16015 Positive Notice (PDF, 134 KB) PDF 7/1/2008 English
F-16015S Positive Notice - Spanish Word 7/1/2008 Spanish
F-16015S Positive Notice - Spanish (PDF, 46 KB) PDF 7/1/2008 Spanish
F-16022 Social Security Number Referral (PDF, 61 KB) PDF 7/1/2008 English
F-16022H Social Security Number Referral - Hmong (PDF, 28 KB) PDF 7/1/2008 Hmong
F-16022S Social Security Number Referral - Spanish (PDF, 26 KB) PDF 7/1/2008 Spanish
F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) PDF 2/1/2014 English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) PDF 2/1/2014 English
F-16036 Self-Employment Income Worksheet - Partnership (PDF, 27 KB) PDF 2/1/2014 English
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) PDF 2/1/2014 English
F-16037A Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) PDF 6/1/2014 English
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) PDF 8/1/2011 English
F-16104 Local Agency Customer Feedback (PDF, 17 KB) Paper 11/1/2009 English
F-16104H Local Agency Customer Feedback (PDF, 17 KB) PDF 11/1/2009 English
F-16104S Local Agency Customer Feedback - Spanish (PDF, 16 KB) Paper 11/1/2009 Spanish