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Eligibility Management (Income Maintenance) Home >> IM Forms

Family Care Forms Sorted by Form Title

Last Revised: March 26, 2014

This list contains all Family Care program 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
A Guide for People Who Are on a Waiting List for Publicly Funded Long-Term Care - Hmong (PDF, 44 KB) P-00088_H PDF 3/1/2009 Hmong
A Guide for People Who Are on a Waiting List for Publicly Funded Long-Term Care - Russian (PDF, 176 KB) P-00088_R PDF 3/1/2009 Russian
A Guide for People Who Are on a Waiting List for Publicly Funded Long-Term Care - Spanish (PDF, 51 KB) P-00088_S PDF 3/1/2009 Spanish
Appeal Request - MCOs F-00237 Word 3/1/2012 English
Being A Full Partner In Family Care (PDF, 187 KB) P-23189 Paper 3/1/2014 English
Being A Full Partner In Family Care - LARGE PRINT (PDF, 151 KB) P-23189L Paper 3/1/2014 English
Being A Full Partner In Family Care - Russian (PDF, 261 KB) P-23189R PDF 3/1/2014 Russian
Being a Full Partner in Family Care - Spanish (PDF, 126 KB) P-23189S PDF 3/1/2014 Spanish
Being a Full Partner In Family Care, Braille P-23189B Paper 3/1/2014 Braille
Being A Full Partner In Family Care, Hmong (PDF, 130 KB) P-23189H PDF 3/1/2014 Hmong
Covered Services in Wisconsin's Long-Term Care Programs (PDF, 92 KB) P-00088O PDF 3/1/2014 English
Covered Services in Wisconsin's Long-Term Care Programs - Russian (PDF, 288 KB) P-00088OR PDF 3/1/2014 Russian
Covered Services…in Wisconsin's Long-Term Care Programs - Hmong (PDF, 73 KB) P-00088OH PDF 3/1/2014 Hmong
Covered Services…in Wisconsin's Long-Term Care Programs - Spanish (PDF, 67 KB) P-00088OS PDF 3/1/2014 Spanish
Estate Recovery Program (ERP) Disclosure (PDF, 30 KB) F-13039 PDF 7/1/2008 English
Estate Recovery Program (ERP) Disclosure Instructions (PDF, 20 KB) F-13039A PDF 7/1/2008 English
Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan F-00395 Word 8/1/2011 English
Family Care / IRIS Member Requested Disenrollment F-00221 Word 1/1/2012 English
Family Care / IRIS Member Requested Disenrollment - Instructions (PDF, 26 KB) F-00221i PDF 1/1/2012 English
Family Care / Partnership / PACE / IRIS - Disenrollment Routing F-00221A Word 1/1/2012 English
Family Care / Partnership / PACE / IRIS - Disenrollment Routing - Instructions (PDF, 19 KB) F-00221Ai PDF 1/1/2012 English
Family Care / Partnership / PACE / IRIS - Refusal to Accept Services and MCO Requested Disenrollment Routing F-00221B Word 1/1/2012 English
Family Care Audit Guide (PDF, 74 KB) P-00466 PDF 2/1/2013 English
Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care (PDF, 49 KB) P-00088P PDF 3/1/2011 English
Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care - Hmong (PDF, 53 KB) P-00088PH PDF 3/1/2011 Hmong
Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care - Russian (PDF, 234 KB) P-00088PR PDF 3/1/2011 Russian
Family Care Benefit Packages: Nursing Home and Non-Nursing Home Level of Care - Spanish (PDF, 53 KB) P-00088PS PDF 3/1/2011 Spanish
Family Care Financial Evaluation (PDF, 664 KB) P-00244 PDF 12/1/2010 English
Family Care Member Survey Results P-00717 PDF 7/1/2014 English
Family Care Program Enrollment Instructions and Important Information F-00046 Word 6/1/2012 English
Family Care, Family Care Partnership and PACE FInancial Summary Overview (PDF, 199 KB) P-00599A PDF 1/1/2014 English
Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request F-00152A Excel 9/1/2009 English
Interdisciplinary Teams in Family Care (PDF, 47 KB) P-00088E PDF 3/1/2009 English
Interdisciplinary Teams in Family Care - Hmong (PDF, 52 KB) P-00088EH PDF 3/1/2009 Hmong
Interdisciplinary Teams in Family Care - Russian (PDF, 146 KB) P-00088ER PDF 3/1/2009 Russian
Interdisciplinary Teams in Family Care - Spanish (PDF, 52 KB) P-00088ES PDF 3/1/2009 Spanish
Interdisciplinary Teams in Family Care Partnership (PDF, 44 KB) P-00088G PDF 3/1/2009 English
Interdisciplinary Teams in Family Care Partnership - Hmong (PDF, 50 KB) P-00088GH PDF 3/1/2009 Hmong
Interdisciplinary Teams in Family Care Partnership - Russian (PDF, 148 KB) P-00088GR PDF 3/1/2009 Russian
Interdisciplinary Teams in Family Care Partnership - Spanish (PDF, 49 KB) P-00088GS PDF 3/1/2009 Spanish
Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) (PDF, 46 KB) P-00088i PDF 3/1/2009 English
Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) - Hmong (PDF, 52 KB) P-00088iH PDF 3/1/2009 Hmong
Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) - Russian (PDF, 153 KB) P-00088iR PDF 3/1/2009 Russian
Interdisciplinary Teams in Program of All-Inclusive Care for the Elderly (PACE) - Spanish (PDF, 51 KB) P-00088iS PDF 3/1/2009 Spanish
Joint Committee on Finance - Long-Term Care Expansion Report (PDF, 1 MB) P-00590 PDF 12/1/2013 English
Key Differences between Family Care, Partnership, and PACE (PDF, 42 KB) P-00088J PDF 3/1/2011 English
Key Differences between Family Care, Partnership, and PACE - Hmong (PDF, 44 KB) P-00088JH PDF 3/1/2011 Hmong
Key Differences between Family Care, Partnership, and PACE - Russian (PDF, 245 KB) P-00088JR PDF 3/1/2011 Russian
Key Differences between Family Care, Partnership, and PACE - Spanish (PDF, 44 KB) P-00088JS PDF 3/1/2011 Spanish
Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS (PDF, 41 KB) P-00088N PDF 3/1/2011 English
Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS - Hmong (PDF, 43 KB) P-00088NH PDF 3/1/2011 Hmong
Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS - Russian (PDF, 104 KB) P-00088NR PDF 3/1/2011 Russian
Key Questions: Highlighting Differences between options for self-direction in Family Care/Partnership/PACE and IRIS - Spanish (PDF, 42 KB) P-00088NS PDF 3/1/2011 Spanish
Letter - Notice to Current COP Participants-Model F-01281 Word 7/1/2014 English
Letter - Notice to Current COP-W, CIP and Brain Injury Waiver Participants-Model F-01281A Word 7/1/2014 English
Living my Dream - Family Care, and IRIS (Manual) (PDF, 2 MB) P-00413 PDF 10/1/2012 English
Living my Dream - Family Care, and IRIS (Pamphletl) (PDF, 1.1 MB) P-00418 PDF 10/1/2012 English
Living my Dream - Partnership, Family Care, and IRIS (Manual) (PDF, 2 MB) P-00413A PDF 10/1/2012 English
Living my Dream - Partnership, Family Care, and IRIS (Pamphlet) (PDF, 629 KB) P-00418A PDF 10/1/2012 English
Living my Dream - Waiver (Manual) (PDF, 1.8 MB) P-00413B PDF 10/1/2012 English
Living my Dream - Waiver (Pamphlet) (PDF, 616 KB) P-00418B PDF 10/1/2012 English
Long Term Care in Motion - WI Long Term Care Programs - Annual Report (PDF, 1.1 MB) P-00318 PDF 5/1/2013 English
MCO Request to Pay Over the Medicaid Fee-for-Service Reimbursement Rate F-00152 Word 1/1/2011 English
Medical and Remedial Expenses Checklist - Update F-00295 Word 3/1/2012 English
Monthly Enrollment Discrepancy Report Template-Model F-01282 Excel 7/1/2014 English
Non-Nursing Home Level of Care Benefit Options (PDF, 39 KB) P-00088Q PDF 3/1/2009 English
Non-Nursing Home Level of Care Benefit Options - Hmong (PDF, 47 KB) P-00088QH PDF 3/1/2009 Hmong
Non-Nursing Home Level of Care Benefit Options - Russian (PDF, 181 KB) P-00088QR PDF 3/1/2009 Russian
Non-Nursing Home Level of Care Benefit Options - Spanish (PDF, 46 KB) P-00088QS PDF 3/1/2009 Spanish
Notification of Non-Covered Benefit Letter Template-Model F-01283 Word 7/1/2014 English
Quarterly MCO Consolidated Financial Report Template-Model F-01285 Excel 7/1/2014 English
Quarterly MCO Financial Report Template-Model F-01284 Excel 7/1/2014 English
Request for a State Fair Hearing - MCO F-00236 Word 3/1/2012 English
Self-Directed Supports (SDS) Best Practice Guide P-00593 PDF 1/1/2014 English
Tell Me More About Family Care (PDF, 216 KB) P-00088D PDF 7/1/2014 English
Tell Me More About Family Care - Russian (PDF, 185 KB) P-00088DR PDF 7/1/2014 Russian
Tell Me More About Family Care Partnership (PDF, 255 KB) P-00088F PDF 7/1/2014 English
Tell Me More About Family Care Partnership - Russian (PDF, 97 KB) P-00088FR PDF 7/1/2014 Russian
Tell Me More About IRIS (PDF, 255 KB) P-00088M PDF 7/1/2014 English
Tell Me More About IRIS - Russian (PDF, 82 KB) P-00088MR PDF 7/1/2014 Russian
Tell Me More about Pogram of All-Inclusive Care for the Elderly (PACE) - Spanish (PDF, 30 KB) P-00088HS PDF 1/1/2014 Spanish
Tell Me More About Program of All-Inclusive Care for the Elderly (PACE) (PDF, 311 KB) P-00088H PDF 7/1/2014 English
Tell Me More about Program of All-Inclusive Care for the Elderly (PACE) - Hmong (PDF, 45 KB) P-00088HH PDF 7/1/2014 Hmong
Tell Me More About Program of All-Inclusive Care for the Elderly (PACE) - Russian (PDF, 100 KB) P-00088HR PDF 7/1/2014 Russian
Tell Me More About Self-Directed Supports in Managed Care (PDF, 36 KB) P-00088L PDF 3/1/2009 English
Tell Me More About Self-Directed Supports in Managed Care - Russian (PDF, 187 KB) P-00088LR PDF 3/1/2009 Russian
Tell Me More About…Family Care - Hmong (PDF, 31 KB) P-00088DH PDF 7/1/2014 Hmong
Tell Me More About…Family Care - Spanish (PDF, 28 KB) P-00088DS PDF 7/1/2014 Spanish
Tell Me More about…Family Care Partnership - Hmong (PDF, 46 KB) P-00088FH PDF 7/1/2014 Hmong
Tell Me More about…Family Care Partnership - Spanish (PDF, 28 KB) P-00088FS PDF 7/1/2014 Spanish
Tell Me More about…IRIS - Hmong (PDF, 67 KB) P-00088MH PDF 7/1/2014 Hmong
Tell Me More about…IRIS - Spanish (PDF, 55 KB) P-00088MS PDF 6/1/2014 Spanish
Tell Me More About…Self-Directed Supports in Managed Care - Hmong (PDF, 42 KB) P-00088LH PDF 3/1/2009 Hmong
Tell Me More About…Self-Directed Supports in Managed Care - Spanish (PDF, 41 KB) P-00088LS PDF 3/1/2009 Spanish
Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) F-00009 PDF 12/1/2008 English
What is an Aging and Disability Resource Center? (PDF, 33 KB) P-00088A PDF 3/1/2009 English
What is an Aging and Disability Resource Center? - Hmong (PDF, 38 KB) P-00088AH PDF 3/1/2009 Hmong
What is an Aging and Disability Resource Center? - Russian (PDF, 153 KB) P-00088AR PDF 3/1/2009 Russian
What is an Aging and Disability Resource Center? - Spanish (PDF, 37 KB) P-00088AS PDF 3/1/2009 Spanish
What is the "Long-Term Care Functional Screen" and How is it Used? (PDF, 32 KB) P-00088B PDF 3/1/2011 English
What is the "Long-Term Care Functional Screen" and How is it Used? - Hmong (PDF, 35 KB) P-00088BH PDF 3/1/2011 Hmong
What is the "Long-Term Care Functional Screen" and How is it Used? - Russian (PDF, 146 KB) P-00088BR PDF 3/1/2011 Russian
What is the "Long-Term Care Functional Screen" and How is it Used? - Spanish (PDF, 36 KB) P-00088BS PDF 3/1/2011 Spanish
What will Change? From the Medicaid Waiver Programs to IRIS (PDF, 44 KB) P-00088K PDF 3/1/2011 English
What will Change? From the Medicaid Waiver Programs to IRIS - Hmong (PDF, 45 KB) P-00088KH PDF 3/1/2011 Hmong
What will Change? From the Medicaid Waiver Programs to IRIS - Russian (PDF, 166 KB) P-00088KR PDF 3/1/2011 Russian
What will Change? From the Medicaid Waiver Programs to IRIS - Spanish (PDF, 46 KB) P-00088KS PDF 3/1/2011 Spanish
What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care (PDF, 34 KB) P-00088R PDF 3/1/2009 English
What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care - Hmong (PDF, 39 KB) P-00088RH PDF 3/1/2009 Hmong
What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care - Russian (PDF, 158 KB) P-00088RR PDF 3/1/2009 Russian
What Will Change? From the Medicaid Waiver Programs to Managed Long-Term Care - Spanish (PDF, 39 KB) P-00088RS PDF 3/1/2009 Spanish
Which Long-Term Care Program is Best for Me? Hmong (PDF, 134KB) P-00088TH PDF 7/1/2014 English
Which Long-Term Care Program is Best for Me? Russian (PDF, 129KB) P-00088TR PDF 7/1/2014 English
Which Long-Term Care Program is Best for Me? Spanish (PDF, 24KB) P-00088TS PDF 4/1/2013 English
Which Long-Term Care Program is Best for Me? (PDF, 124KB) P-00088T PDF 7/1/2014 English
Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS (PDF, 124 KB) P-00088C PDF 7/1/2014 English
Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS - Hmong (PDF, 21 KB) P-00088CH PDF 7/1/2014 Hmong
Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS - Russian (PDF, 36 KB) P-00088CR PDF 7/1/2014 Russian
Which Long-Term Care Program is Best for Me? Family Care, Partnership/PACE or IRIS - Spanish (PDF, 35 KB) P-00088CS PDF 7/1/2014 Spanish
Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) F-10101S PDF 2/1/2013 Spanish
Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) F-10101 Paper 2/1/2013 English
Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) F-10101H PDF 2/1/2013 Hmong
Wisconsin Medicaid Standards for Certified 1-2 Bed Adult Family Homes (PDF, 521 KB) P-00638 PDF 4/1/2014 English