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Eligibility Management (Income Maintenance) Home >> IM Forms

Family Care Forms Sorted by Form Number

Last Revised: March 26, 2014

This list contains all Family Care program forms that are available from DHCF. 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-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) PDF 12/1/2008 English
F-00046 Family Care Program Enrollment Instructions and Important Information Word 6/1/2012 English
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) Paper 2/1/2013 English
F-10101H Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) PDF 2/1/2013 Hmong
F-10101S Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) PDF 2/1/2013 Spanish
F-13039 Estate Recovery Program (ERP) Disclosure (PDF, 30 KB) PDF 7/1/2008 English
F-13039A Estate Recovery Program (ERP) Disclosure Instructions (PDF, 20 KB) PDF 7/1/2008 English
P-00088_H A Guide for People Who Are on a Waiting List for Publicly Funded Long-Term Care - Hmong (PDF, 44 KB) PDF 3/1/2009 Hmong
P-00088_R A Guide for People Who Are on a Waiting List for Publicly Funded Long-Term Care - Russian (PDF, 176 KB) PDF 3/1/2009 Russian
P-00088_S A Guide for People Who Are on a Waiting List for Publicly Funded Long-Term Care - Spanish (PDF, 51 KB) PDF 3/1/2009 Spanish
P-00088A What is an Aging and Disability Resource Center? (PDF, 33 KB) PDF 3/1/2009 English
P-00088AH What is an Aging and Disability Resource Center? - Hmong (PDF, 38 KB) PDF 3/1/2009 Hmong
P-00088AR What is an Aging and Disability Resource Center? - Russian (PDF, 153 KB) PDF 3/1/2009 Russian
P-00088AS What is an Aging and Disability Resource Center? - Spanish (PDF, 37 KB) PDF 3/1/2009 Spanish
P-00088B What is the "Long-Term Care Functional Screen" and How is it Used? (PDF, 32 KB) PDF 3/1/2011 English
P-00088BH What is the "Long-Term Care Functional Screen" and How is it Used? - Hmong (PDF, 35 KB) PDF 3/1/2011 Hmong
P-00088BR What is the "Long-Term Care Functional Screen" and How is it Used? - Russian (PDF, 146 KB) PDF 3/1/2011 Russian
P-00088BS What is the "Long-Term Care Functional Screen" and How is it Used? - Spanish (PDF, 36 KB) PDF 3/1/2011 Spanish
P-00088C Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS (PDF, 21KB) PDF 2/1/2013 English
P-00088CH Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS - Hmong (PDF, 21 KB) PDF 2/1/2013 Hmong
P-00088CR Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS - Russian (PDF, 36 KB) PDF 2/1/2013 Russian
P-00088CS Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS - Spanish (PDF, 35 KB) PDF 2/1/2013 Spanish
P-00088D Tell Me More About Family Care (PDF, 27 KB) PDF 2/1/2013 English
P-00088DH Tell Me More About…Family Care - Hmong (PDF, 31 KB) PDF 2/1/2013 Hmong
P-00088DR Tell Me More About Family Care - Russian (PDF, 185 KB) PDF 2/1/2013 Russian
P-00088DS Tell Me More About…Family Care - Spanish (PDF, 28 KB) PDF 2/1/2013 Spanish
P-00088E Interdisciplinary Teams in Family Care (PDF, 47 KB) PDF 3/1/2009 English
P-00088EH Interdisciplinary Teams in Family Care - Hmong (PDF, 52 KB) PDF 3/1/2009 Hmong
P-00088ER Interdisciplinary Teams in Family Care - Russian (PDF, 146 KB) PDF 3/1/2009 Russian
P-00088ES Interdisciplinary Teams in Family Care - Spanish (PDF, 52 KB) PDF 3/1/2009 Spanish
P-00088F Tell Me More About Family Care Partnership (PDF, 27 KB) PDF 2/1/2013 English
P-00088FH Tell Me More about…Family Care Partnership - Hmong (PDF, 46 KB) PDF 2/1/2013 Hmong
P-00088FR Tell Me More About Family Care Partnership - Russian (PDF, 97 KB) PDF 2/1/2013 Russian
P-00088FS Tell Me More about…Family Care Partnership - Spanish (PDF, 28 KB) PDF 2/1/2013 Spanish
P-00088G Interdisciplinary Teams in Family Care Partnership (PDF, 44 KB) PDF 3/1/2009 English
P-00088GH Interdisciplinary Teams in Family Care Partnership - Hmong (PDF, 50 KB) PDF 3/1/2009 Hmong
P-00088GR Interdisciplinary Teams in Family Care Partnership - Russian (PDF, 148 KB) PDF 3/1/2009 Russian
P-00088GS Interdisciplinary Teams in Family Care Partnership - Spanish (PDF, 49 KB) PDF 3/1/2009 Spanish
P-00088H Tell Me More About Program of All-Inclusive Care for the Elderly (PACE) (PDF, 27 KB) PDF 1/1/2014 English
P-00088HH Tell Me More about Program of All-Inclusive Care for the Elderly (PACE) - Hmong (PDF, 45 KB) PDF 1/1/2014 Hmong
P-00088HR Tell Me More About Program of All-Inclusive Care for the Elderly (PACE) - Russian (PDF, 100 KB) PDF 1/1/2014 Russian
P-00088HS Tell Me More about Pogram of All-Inclusive Care for the Elderly (PACE) - Spanish (PDF, 30 KB) PDF 1/1/2014 Spanish
P-00088i Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) (PDF, 46 KB) PDF 3/1/2009 English
P-00088iH Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) - Hmong (PDF, 52 KB) PDF 3/1/2009 Hmong
P-00088iR Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) - Russian (PDF, 153 KB) PDF 3/1/2009 Russian
P-00088iS Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) - Spanish (PDF, 51 KB) PDF 3/1/2009 Spanish
P-00088J Key Differences between Family Care, Partnership, and PACE (PDF, 42 KB) PDF 3/1/2011 English
P-00088JH Key Differences between Family Care, Partnership, and PACE - Hmong (PDF, 44 KB) PDF 3/1/2011 Hmong
P-00088JR Key Differences between Family Care, Partnership, and PACE - Russian (PDF, 245 KB) PDF 3/1/2011 Russian
P-00088JS Key Differences between Family Care, Partnership, and PACE - Spanish (PDF, 44 KB) PDF 3/1/2011 Spanish
P-00088K What will Change? From the Medicaid Waiver Programs to IRIS (PDF, 44 KB) PDF 3/1/2011 English
P-00088KH What will Change? From the Medicaid Waiver Programs to IRIS - Hmong (PDF, 45 KB) PDF 3/1/2011 Hmong
P-00088KR What will Change? From the Medicaid Waiver Programs to IRIS - Russian (PDF, 166 KB) PDF 3/1/2011 Russian
P-00088KS What will Change? From the Medicaid Waiver Programs to IRIS - Spanish (PDF, 46 KB) PDF 3/1/2011 Spanish
P-00088L Tell Me More About Self-Directed Supports in Managed Care (PDF, 36 KB) PDF 3/1/2009 English
P-00088LH Tell Me More About…Self-Directed Supports in Managed Care - Hmong (PDF, 42 KB) PDF 3/1/2009 Hmong
P-00088LR Tell Me More About Self-Directed Supports in Managed Care - Russian (PDF, 187 KB) PDF 3/1/2009 Russian
P-00088LS Tell Me More About…Self-Directed Supports in Managed Care - Spanish (PDF, 41 KB) PDF 3/1/2009 Spanish
P-00088M Tell Me More About IRIS (PDF, 114 KB) PDF 3/1/2014 English
P-00088MH Tell Me More about…IRIS - Hmong (PDF, 67 KB) PDF 3/1/2014 Hmong
P-00088MR Tell Me More About IRIS - Russian (PDF, 82 KB) PDF 3/1/2014 Russian
P-00088MS Tell Me More about…IRIS - Spanish (PDF, 55 KB) PDF 6/1/2014 Spanish
P-00088N Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS (PDF, 41 KB) PDF 3/1/2011 English
P-00088NH Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS - Hmong (PDF, 43 KB) PDF 3/1/2011 Hmong
P-00088NR Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS - Russian (PDF, 104 KB) PDF 3/1/2011 Russian
P-00088NS Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS - Spanish (PDF, 42 KB) PDF 3/1/2011 Spanish
P-00088O Covered Services in Wisconsin's Long-Term Care Programs (PDF, 92 KB) PDF 3/1/2014 English
P-00088OH Covered Services…in Wisconsin's Long-Term Care Programs - Hmong (PDF, 73 KB) PDF 3/1/2014 Hmong
P-00088OR Covered Services in Wisconsin's Long-Term Care Programs - Russian (PDF, 288 KB) PDF 3/1/2014 Russian
P-00088OS Covered Services…in Wisconsin's Long-Term Care Programs - Spanish (PDF, 67 KB) PDF 3/1/2014 Spanish
P-00088P Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care (PDF, 49 KB) PDF 3/1/2011 English
P-00088PH Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care - Hmong (PDF, 53 KB) PDF 3/1/2011 Hmong
P-00088PR Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care - Russian (PDF, 234 KB) PDF 3/1/2011 Russian
P-00088PS Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care - Spanish (PDF, 53 KB) PDF 3/1/2011 Spanish
P-00088Q Non-Nursing Home Level of Care Benefit Options (PDF, 39 KB) PDF 3/1/2009 English
P-00088QH Non-Nursing Home Level of Care Benefit Options - Hmong (PDF, 47 KB) PDF 3/1/2009 Hmong
P-00088QR Non-Nursing Home Level of Care Benefit Options - Russian (PDF, 181 KB) PDF 3/1/2009 Russian
P-00088QS Non-Nursing Home Level of Care Benefit Options - Spanish (PDF, 46 KB) PDF 3/1/2009 Spanish
P-00088R What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care (PDF, 34 KB) PDF 3/1/2009 English
P-00088RH What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care - Hmong (PDF, 39 KB) PDF 3/1/2009 Hmong
P-00088RR What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care - Russian (PDF, 158 KB) PDF 3/1/2009 Russian
P-00088RS What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care - Spanish (PDF, 39 KB) PDF 3/1/2009 Spanish
P-00088T Which Long-Term Care Program is Best for Me? Family Care or IRIS (PDF, 28KB) PDF 4/1/2013 English
P-00088TH Which Long-Term Care Program is Best for Me? Family Care or IRIS - Hmong (PDF, 23KB) PDF 4/1/2013 English
P-00088TR Which Long-Term Care Program is Best for Me? Family Care or IRIS - Russian (PDF, 37KB) PDF 4/1/2013 English
P-00088TS Which Long-Term Care Program is Best for Me? Family Care or IRIS - Spanish (PDF, 24KB) PDF 4/1/2013 English
P-00413 Living my Dream - Family Care, and IRIS (Manual) (PDF, 2 MB) PDF 10/1/2012 English
P-00413A Living my Dream - Partnership, Family Care, and IRIS (Manual) (PDF, 2 MB) PDF 10/1/2012 English
P-00413B Living my Dream - Waiver (Manual) (PDF, 1.8 MB) PDF 10/1/2012 English
P-00418 Living my Dream - Family Care, and IRIS (Pamphletl) (PDF, 1.1 MB) PDF 10/1/2012 English
P-00418A Living my Dream - Partnership, Family Care, and IRIS (Pamphlet) (PDF, 629 KB) PDF 10/1/2012 English
P-00418B Living my Dream - Waiver (Pamphlet) (PDF, 616 KB) PDF 10/1/2012 English
P-23189 Being A Full Partner In Family Care (PDF, 187 KB) Paper 3/1/2014 English
P-23189B Being a Full Partner In Family Care, Braille Paper 3/1/2014 Braille
P-23189H Being A Full Partner In Family Care, Hmong (PDF, 130 KB) PDF 3/1/2014 Hmong
P-23189L Being A Full Partner In Family Care - LARGE PRINT (PDF, 151 KB) Paper 3/1/2014 English
P-23189R Being A Full Partner In Family Care - Russian (PDF, 261 KB) PDF 3/1/2014 Russian
P-23189S Being a Full Partner in Family Care - Spanish (PDF, 126 KB) PDF 3/1/2014 Spanish