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Eligibility Management (Income Maintenance) Home >> IM Forms

BadgerCare Plus Forms Sorted by Form Title

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 Title Form Number Form Type Revised Date Language
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 / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) F-10115S PDF 1/1/2011 Spanish
BadgerCare Plus Application Packet (PDF, 2417 KB) F-10182 Paper 4/1/2014 English
BadgerCare Plus Application Packet - Hmong (PDF, 1310 KB) F-10182H PDF 4/1/2014 Hmong
BadgerCare Plus Application Packet - Spanish (PDF, 1460 KB) F-10182S PDF 4/1/2014 Spanish
BadgerCare Plus Change Report (PDF, 345 KB) F-10183 Paper 11/1/2013 English
BadgerCare Plus Change Report - Hmong (PDF, 284 KB) F-10183H PDF 11/1/2013 Hmong
BadgerCare Plus Change Report - Spanish (PDF, 340 KB) F-10183S PDF 11/1/2013 Spanish
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 Information / Payment - Spanish (PDF, 37 KB) F-10139S PDF 7/1/2012 Spanish
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 - Spanish (PDF, 249 KB) F-00914S PDF 12/1/2013 Spanish
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 9/1/2014 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 (Hmong) (PDF, 55 KB) F-16104H PDF 8/1/2014 English
Local Agency Customer Feedback (PDF, 129 KB) F-16104 Paper 8/1/2014 English
Local Agency Customer Feedback - Spanish (PDF, 29 KB) F-16104S Paper 8/1/2014 Spanish
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 PDF 2/1/2013 English
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H PDF 2/1/2013 Hmong
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S PDF 2/1/2013 Spanish
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) F-10129 PDF 9/1/2013 English
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) F-10129H PDF 9/1/2013 Hmong
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 Overpayment Notice - Spanish (PDF, 59 KB) F-10093S PDF 9/1/2013 Spanish
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
Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) F-10129S PDF 9/1/2013 Spanish
Negative Notice F-16001 Word 7/1/2008 English
Negative Notice (PDF, 154 KB) F-16001 PDF 7/1/2008 English
Negative Notice - Spanish F-16001S Word 7/1/2008 Spanish
Negative Notice - Spanish (PDF, 74 KB) F-16001S PDF 7/1/2008 Spanish
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
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 F-00233 Word 4/1/2010 English
Renewal Summary Letter (Hmong) F-00233H Word 4/1/2010 Hmong
Renewal Summary Letter (Spanish) F-00233S Word 4/1/2010 Spanish
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 Report - Farmer - Hmong (PDF, 82 KB) F-00219H PDF 6/1/2013 Hmong
Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S PDF 6/1/2013 Spanish
Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H PDF 4/1/2013 Hmong
Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S PDF 4/1/2013 Spanish
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
Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H PDF 7/1/2008 Hmong
Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S PDF 7/1/2008 Spanish
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 Children Under 18 Years of Age - Hmong (PDF, 33 KB) F-10154H PDF 7/1/2008 Hmong
Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) F-10154R PDF 7/1/2008 Russian
Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) F-10154S PDF 7/1/2008 Spanish
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, 71 KB) F-10150S PDF 9/1/2013 Spanish
Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 PDF 9/1/2013 English