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Eligibility Management (Income Maintenance) Home >> IM Forms

Family Care Forms Sorted by Form Type

Last Revised: March 26, 2014

This list contains all Family Care program forms that are available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). 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 Type Form Title Form Number Revised Date Language
Paper Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) F-10101 2/1/2013 English
PDF Estate Recovery Program (ERP) Disclosure (PDF, 30 KB) F-13039 7/1/2008 English
PDF Estate Recovery Program (ERP) Disclosure Instructions (PDF, 20 KB) F-13039A 7/1/2008 English
PDF Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) F-00009 12/1/2008 English
PDF Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) F-10101S 2/1/2013 Spanish
PDF Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) F-10101H 2/1/2013 Hmong