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 Publicatons

FoodShare  Publications

Medicaid Publications

Training

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