Department of Health Services Logo

 

Wisconsin Department of Health Services

Operations Memos

BadgerCare Plus Handbook

Medicaid Eligibility Handbook

FoodShare Wisconsin  Handbook

Income Maintenance Manual

Income Maintenance Forms

BadgerCare Plus  Publications

FoodShare  Publications

Medicaid Publications

Training

Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: July 12, 2010

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
Administrative Disqualification Hearing Notice F-16038 PDF 10/1/2011 English
Agency Position on the Payment Error Rate Measurement (PERM) Error Finding F-10171 PDF 7/1/2008 English
Agency Response to the State Quality Assurance (QA) Medicaid Finding F-10172 PDF 7/1/2008 English
Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children F-10148 PDF 10/1/2008 English
Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children F-10148 Word 10/1/2008 English
Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women F-10177 PDF 10/1/2008 English
Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women F-10177 Word 10/1/2008 English
Authorization to Request Birth Records F-00101 Word 6/1/2009 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 F-10081A PDF 10/1/2008 English
BadgerCare Plus / Medicaid Health Insurance Information F-10115 PDF 1/1/2011 English
BadgerCare Plus / Medicaid Health Insurance Information - Spanish F-10115S PDF 1/1/2011 Spanish
BadgerCare Plus Application / Review Packet F-10182 PDF 7/1/2011 English
BadgerCare Plus Application / Review Packet - Spanish F-10182S PDF 10/1/2008 Spanish
BadgerCare Plus Application Packet - Hmong F-10182H PDF 7/1/2008 Hmong
BadgerCare Plus Change Report F-10183 PDF 7/1/2008 English
BadgerCare Plus Change Report - Hmong F-10183H PDF 7/1/2008 Hmong
BadgerCare Plus Change Report - Spanish F-10183S PDF 7/1/2008 Spanish
BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication F-10185 Word 7/1/2008 English
BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 PDF 10/1/2008 English
BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 Word 10/1/2008 English
BadgerCare Plus Premium Employer Wage Withholding F-13025 PDF 7/1/2008 English
BadgerCare Plus Premium Information F-10139 PDF 6/1/2009 English
BadgerCare Plus Premium Information - Spanish F-10139S PDF 6/1/2009 Spanish
BadgerCare Plus Premium Member / Employer Electronic Funds Transfer F-13026 PDF 7/1/2008 English
BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 PDF 7/1/2008 English
BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) F-10184 Word 7/1/2008 English
Designation of a BadgerCare Plus Essential Person F-10186 PDF 7/1/2008 English
Employer Health Insurance Verification Individual Follow-Up Health Insurance Information F-00246 PDF 10/1/2010 English
Employment Verification of Earnings F-10146 Word 7/1/2008 English
Enrollment Services Center State Vital Records Letter F-00100E Word 6/1/2009 English
Good Faith Medicaid / BadgerCare Plus Certification F-10111 PDF 2/1/2009 English
Good Faith Medicaid / BadgerCare Plus Certification Instructions F-10111A PDF 2/1/2009 English
Income Maintenance Quality Assurance (IMQA) Web Request F-16083 PDF 8/1/2011 English
Information Regarding Your BadgerCare Plus Core Plan Request F-00333 Word 12/1/2010 English
Life Insurance Inquiry F-10144 Word 7/1/2008 English
Local Agency Customer Feedback F-16104 PDF 11/1/2009 English
Local Agency Customer Feedback - Spanish F-16104S PDF 11/1/2009 Spanish
Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S PDF 7/1/2008 Spanish
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 PDF 7/1/2008 English
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong F-10126H PDF 7/1/2008 Hmong
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish F-10126S PDF 7/1/2008 Spanish
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application F-10129 PDF 6/1/2009 English
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong F-10129H PDF 6/1/2009 Hmong
Medicaid / BadgerCare Plus Certification F-10110 System 11/1/2008 English
Medicaid / BadgerCare Plus Fair Hearing Information F-10151 PDF 7/1/2008 English
Medicaid / BadgerCare Plus Overpayment Notice F-10093 PDF 7/1/2008 English
Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish F-10129S PDF 6/1/2009 Spanish
Negative Notice F-16001 PDF 7/1/2008 English
Negative Notice F-16001 Word 7/1/2008 English
Negative Notice - Spanish F-16001S PDF 7/1/2008 Spanish
New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version F-10180 PDF 7/1/2008 English
Notice of Program Violation F-16014 PDF 7/1/2008 English
Positive Notice F-16015 PDF 7/1/2008 English
Positive Notice F-16015 Word 7/1/2008 English
Positive Notice - Spanish 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 F-00107 PDF 5/1/2010 English
Self-Employment Income Report (Worksheet) F-00107W PDF 5/1/2010 English
Self-Employment Income Report - Farmer F-00219 PDF 5/1/2010 English
Self-Employment Income Report - Farmer (Worksheet) F-00219W PDF 5/1/2010 English
Self-Employment Income Report - Farmer - Hmong F-00219H PDF 5/1/2010 Hmong
Self-Employment Income Report - Farmer - Spanish F-00219S PDF 5/1/2010 Spanish
Self-Employment Income Report - Hmong F-00107H PDF 5/1/2010 Hmong
Self-Employment Income Report - Spanish F-00107S PDF 5/1/2010 Spanish
Self-Employment Income Worksheet - Corporation F-16034 PDF 2/1/2010 English
Self-Employment Income Worksheet - Partnership F-16036 PDF 5/1/2009 English
Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 PDF 5/1/2009 English
Self-Employment Income Worksheet - Subchapter S Corporation F-16035 PDF 5/1/2009 English
Social Security Number Referral F-16022 PDF 7/1/2008 English
Social Security Number Referral - Hmong F-16022H PDF 7/1/2008 Hmong
Social Security Number Referral - Spanish 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 F-10161 PDF 7/1/2008 English
Statement of Identity for Children Under 18 Years of Age F-10154 PDF 7/1/2008 English
Statement of Identity for Children Under 18 Years of Age - Hmong F-10154H PDF 7/1/2008 Hmong
Statement of Identity for Children Under 18 Years of Age - Russian F-10154R PDF 7/1/2008 Russian
Statement of Identity for Children Under 18 Years of Age - Spanish F-10154S PDF 7/1/2008 Spanish
Statement of Identity for Persons in Institutional Care Facilities F-10175 PDF 7/1/2008 English
Summary of Information Letter F-00098 Word 6/1/2009 English
Verification of Veterans Benefits F-10162 PDF 7/1/2008 English
Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice F-10143 PDF 1/1/2011 English
Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 PDF 1/1/2011 English
Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A PDF 1/1/2011 English
Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin F-10150 PDF 7/1/2008 English
Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin - Spanish F-10150S PDF 7/1/2008 Spanish