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Eligibility Management (Income Maintenance)Home >> IM Forms

All Income Maintenance (IM) Forms Sorted by Language

Last Revised: March 26, 2014

This list contains all DHCAA forms that are available from this site sorted by the language in which they are written. 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.

Language  Form Title Form Number Form Type  Revised Date
Arabic FoodShare Wisconsin Change Report - Arabic (PDF, 137 KB) F-16006AR PDF 6/1/2013
Arabic FoodShare Wisconsin Income Change Report - Arabic (PDF, 180 KB) F-16066AR PDF 10/1/2014
Arabic FoodShare Wisconsin Registration / Important Information - Arabic (PDF, 276 KB) F-16019AAR PDF 4/1/2014
English Administrative Disqualification Hearing Notice (PDF, 101 KB) F-16038 PDF 2/1/2014
English Affidavit of Return or Exchange of Food Coupons (PDF, 615 KB) F-19002 PDF 12/1/1997
English Agency Data Security Staff User Agreement F-00639 Word 7/1/2012
English Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding (PDF, 25 KB) F-10145 PDF 7/1/2008
English Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) F-10171 PDF 7/1/2008
English Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) F-10172 PDF 7/1/2008
English Authorization for Recoupment Caretaker Supplement F-22565 Word 7/1/2008
English Authorization for Recoupment Caretaker Supplement (CTS)* (PDF, 14 KB) F-22565 PDF 7/1/2008
English Authorization for Retroactive Caretaker Supplement (CTS)* (PDF, 28 KB) F-22564 PDF 7/1/2008
English Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF, 199 KB) F-14014 PDF 4/1/2013
English Authorization to Request Birth Records F-00101 Word 6/1/2009
English BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) F-10115 PDF 1/1/2011
English BadgerCare Plus Application Packet (PDF, 2417 KB) F-10182 Paper 4/1/2014
English BadgerCare Plus Change Report (PDF, 345 KB) F-10183 Paper 11/1/2013
English BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication F-10185 Word 7/1/2008
English BadgerCare Plus Express Enrollment for Pregnant Women Application F-10081 Paper 2/1/2014
English BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 100 KB) F-10081A PDF 3/1/2014
English BadgerCare Plus Former Foster Care Youth (FFCY) F-10184 Word 11/1/2014
English BadgerCare Plus Premium Employer Wage Withholding (PDF, 92 KB) F-13025 PDF 9/1/2013
English BadgerCare Plus Premium Information / Payment (PDF, 76 KB) F-10139 PDF 7/1/2012
English BadgerCare Plus Premium Member / Employer Electronic Funds Transfer (PDF, 202 KB) F-13026 PDF 5/1/2014
English BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) F-10138 PDF 7/1/2008
English BadgerCare Plus Tax Filer Information (PDF, 238 KB) F-00914 PDF 12/1/2013
English BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) F-00914A PDF 12/1/2013
English Caretaker Supplement (CTS) Instructions for Application (PDF, 47 KB) F-22571A PDF 7/1/2008
English Caretaker Supplement Application (PDF, 218 KB) F-22571 PDF 7/1/2008
English Community Spouse Asset Share Notice (PDF, 658 KB) F-10096 PDF 7/1/2008
English Consortium Response to the State IM Second Party Review Finding F-00628 Word 7/1/2012
English Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) F-00628 PDF 7/1/2012
English Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (PDF, 32 KB) F-16004 PDF 7/1/2008
English Disaster FoodShare Wisconsin Assistance Application (PDF, 118 KB) F-16060 PDF 10/1/2014
English Disqualification Consent Agreement (PDF, 71 KB) F-16025 PDF 2/1/2014
English Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) F-00246 PDF 7/1/2012
English Employment Verification of Earnings F-10146 Word 9/1/2014
English 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 Planning Only Services Authorization for Electronic Data Transfer of Application (PDF, 25 KB) F-00356 PDF 1/1/2011
English Financial Records Request (PDF, 28 KB) F-00407 PDF 4/1/2011
English FoodShare and/or Child Care Six Month Report F-16076 Word 6/1/2014
English FoodShare and/or Child Care Six Month Report Form Instructions F-16076A Word 6/1/2014
English FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) F-00136 PDF 2/1/2012
English FoodShare Employment and Training - Discuss Participant Appointment Letter F-01256 Word 6/1/2014
English FoodShare Employment and Training - Employment Plan (EP) Appointment Letter F-01254 Word 6/1/2014
English FoodShare Employment and Training - Final Notice Appointment Letter F-01253 Word 6/1/2014
English FoodShare Employment and Training - Initial Appointment Letter F-01252 Word 6/1/2014
English FoodShare Employment and Training - Job Club Appointment Letter F-01255 Word 6/1/2014
English FoodShare Employment and Training - Workshop Appointment Letter F-01257 Word 6/1/2014
English FoodShare Renewal Request for a Closed Case F-00363 Word 1/1/2011
English FoodShare Wisconsin Application / Registration (PDF, 657 KB) F-16019B Paper 4/1/2014
English FoodShare Wisconsin Change Report (PDF, 250 KB) F-16006 Paper 6/1/2013
English FoodShare Wisconsin Income Change Report (PDF, 80 KB) F-16066 Paper 10/1/2014
English FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) F-16073 PDF 8/1/2008
English FoodShare Wisconsin Registration / Important Information (PDF, 170 KB) F-16019A Paper 4/1/2014
English FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) F-16029 PDF 7/1/2008
English FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) F-16030 PDF 7/1/2011
English FoodShare Worksheet (PDF, 45 KB) F-16033 PDF 7/1/2011
English Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) F-10111 PDF 9/1/2013
English Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) F-10111A PDF 9/1/2013
English Historical Earnings Verification Request F-01359 Word 9/1/2014
English How the Affordable Care Act may affect SeniorCare members who get Prescriptions (PDF, 62 KB) F-00985 PDF 4/1/2014
English Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 PDF 8/1/2011
English Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF, 107 KB) F-10142 PDF 7/1/2008
English Life Insurance Inquiry F-10144 Word 7/1/2008
English Local Agency Customer Feedback (Hmong) (PDF, 55 KB) F-16104H PDF 8/1/2014
English Local Agency Customer Feedback (PDF, 129 KB) F-16104 Paper 8/1/2014
English Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) F-10191 PDF 1/1/2009
English Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 PDF 2/1/2013
English Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) F-10129 PDF 9/1/2013
English Medicaid / BadgerCare Plus Certification F-10110 System 4/1/2011
English Medicaid / BadgerCare Plus Certification Instructions F-10110A System 4/1/2011
English Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) F-10151 PDF 7/1/2008
English Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) F-10109 PDF 2/1/2014
English Medicaid and BadgerCare Plus Overpayment Notice F-10093 Word 9/1/2013
English Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) F-10093 PDF 9/1/2013
English Medicaid and BadgerCare Plus Overpayment Notice - Spanish F-10093S Word 9/1/2013
English Medicaid Annuity Information - Disclosure (PDF, 2.1 MB) F-10192 PDF 1/1/2009
English Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (PDF, 395 KB) F-10095 PDF 7/1/2008
English Medicaid Change Report (PDF, 88 KB) F-10137 Paper 1/1/2014
English Medicaid Disability Application (PDF, 1982 KB) F-10112 Paper 3/1/2012
English Medicaid Disability Redetermination Report (PDF, 222 KB) F-10114 PDF 2/1/2013
English Medicaid Divestment Penalty and Undue Hardship Notice F-10187 Word 1/1/2009
English Medicaid Income Allocation Notice (PDF, 44 KB) F-10097 PDF 2/1/2009
English Medicaid Issuer of Annuity - Notice of Obligation (PDF, 641 KB) F-10190 PDF 1/1/2009
English Medicaid Manual Notice for Cost of Care Contribution (PDF, 168 KB) F-10108 PDF 7/1/2008
English Medicaid Manual Notice for Cost of Care Contribution Instructions (PDF, 509 KB) F-10108A PDF 7/1/2008
English Medicaid Member Asset Allocation Notice (PDF, 85 KB) F-10098 PDF 11/1/2013
English Medicaid Presumptive Disability (PDF, 51 KB) F-10130 PDF 4/1/2012
English Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) F-10127 PDF 7/1/2008
English Medicaid Purchase Plan (MAPP) Independence Account Registration (PDF, 29 KB) F-10121 PDF 9/1/2008
English Medicaid Purchase Plan (MAPP) Member / Premium Information (PDF, 117 KB) F-10122 PDF 7/1/2008
English Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions (PDF, 1.4 MB) F-13024 PDF 7/1/2008
English Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions (PDF, 1.3 MB) F-13023 PDF 7/1/2008
English Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) F-00332 PDF 11/1/2010
English Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice (PDF, 342 KB) F-10106 PDF 7/1/2008
English Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice (PDF, 477 KB) F-10107 PDF 7/1/2008
English Medicaid Undue Hardship Bedhold Notice F-10189 Word 1/1/2009
English Medicaid Undue Hardship Request (PDF, 2.7 MB) F-10193 PDF 1/1/2009
English Medicaid Undue Hardship Waiver Decision F-10188 Word 1/1/2009
English Negative Notice F-16001 Word 7/1/2008
English Negative Notice (PDF, 154 KB) F-16001 PDF 7/1/2008
English New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) F-10180 PDF 7/1/2008
English Notice of Disqualification (PDF, 110 KB) F-16024 PDF 2/1/2014
English Notice of FoodShare Over issuance (PDF, 288 KB) F-16028 PDF 7/1/2008
English Notice of Program Violation (PDF, 43 KB) F-16014 PDF 7/1/2008
English Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB) F-10099 PDF 7/1/2008
English Positive Notice F-16015 Word 7/1/2008
English Positive Notice (PDF, 134 KB) F-16015 PDF 7/1/2008
English Prosecution Diversion Agreement (PDF, 251 KB) F-16026 PDF 7/1/2008
English Quality Assurance (QA) Sample Check List (PDF, 226 KB) F-16011 PDF 7/1/2008
English Renewal Summary Letter F-00233 Word 4/1/2010
English Request for Replacement FoodShare Benefits (PDF, 28 KB) F-00330 PDF 6/1/2013
English Self-Employment Income Report (PDF, 91 KB) F-00107 PDF 5/1/2013
English Self-Employment Income Report (Worksheet) (PDF, 37 KB) F-00107W PDF 6/1/2014
English Self-Employment Income Report - Farmer (PDF, 74 KB) F-00219 PDF 6/1/2013
English Self-Employment Income Report - Farmer (Worksheet) (PDF, 37 KB) F-00219W PDF 6/1/2014
English Self-Employment Income Worksheet - Corporation (PDF, 25 KB) F-16034 PDF 2/1/2014
English Self-Employment Income Worksheet - Partnership (PDF, 27 KB) F-16036 PDF 2/1/2014
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) F-16037 PDF 2/1/2014
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) F-16037A PDF 6/1/2014
English Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) F-16035 PDF 2/1/2014
English SeniorCare Application (PDF, 179 KB) F-10076 Paper 10/1/2008
English SeniorCare Authorization of Representative (PDF, 486 KB) F-10080 PDF 7/1/2008
English SeniorCare Instructions for Application Form (PDF, 71 KB) F-10076A Paper 9/1/2011
English Social Security Number Referral (PDF, 61 KB) F-16022 PDF 7/1/2008
English State Vital Records Cover Letter F-00100 Word 6/1/2009
English Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) F-10161 PDF 7/1/2008
English Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) F-10154 PDF 7/1/2008
English Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) F-10175 PDF 9/1/2013
English Statement of Tribal Affiliation (PDF, 24 KB) F-00685 PDF 11/1/2012
English Striker Evaluation (PDF, 395 KB) F-16023 PDF 7/1/2008
English Student Aid and Expense Worksheet (PDF, 256 KB) F-16031 PDF 7/1/2008
English Student Financial Report (PDF, 194 KB) F-16021 PDF 7/1/2008
English Summary of Information Letter (PDF, 224 KB) F-00098 PDF 6/1/2009
English Temporary Enrollment For Family Planning Only Services F-10119 Paper 2/1/2014
English Temporary Enrollment For Family Planning Only Services Instructions (PDF, 279 KB) F-10119A PDF 3/1/2014
English Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) F-00009 PDF 12/1/2008
English Verification of Veterans Benefits (PDF, 53 KB) F-10162 PDF 1/1/2014
English Waiver of Administrative Disqualification Hearing (PDF, 141 KB) F-16039 PDF 2/1/2014
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) F-10143 PDF 11/1/2013
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) F-10141 PDF 11/1/2013
English Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) F-10101 Paper 2/1/2013
English Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) F-10140 PDF 10/1/2012
English Wisconsin Veterans Home at King - Medicaid Review (PDF, 253 KB) F-10147 PDF 7/1/2008
English Wisconsin Well Woman Medicaid Determination (PDF, 78 KB) F-10075 Paper 1/1/2014
English Your Rights and Responsibilities for FoodShare (PDF, 81 KB) F-10150B PDF 9/1/2013
English Your Rights and Responsibilities for FoodShare - Spanish (PDF, 60 KB) F-10150BS PDF 9/1/2013
English Your Rights and Responsibilities for Health Care (PDF, 56 KB) F-10150A PDF 10/1/2012
English Your Rights and Responsibilities for Health Care - Spanish (PDF, 56 KB) F-10150AS PDF 10/1/2012
English Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 PDF 9/1/2013
Hmong BadgerCare Plus Application Packet - Hmong (PDF, 1310 KB) F-10182H PDF 4/1/2014
Hmong BadgerCare Plus Change Report - Hmong (PDF, 284 KB) F-10183H PDF 11/1/2013
Hmong Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong (PDF, 31 KB) F-16004H PDF 7/1/2008
Hmong FoodShare and/or Child Care Six Month Report (Hmong) F-16076H Word 1/1/2012
Hmong FoodShare and/or Child Care Six Month Report Form Instructions - Hmong F-16076AH Word 1/1/2012
Hmong FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 42 KB) F-00136H PDF 2/1/2012
Hmong FoodShare Renewal Request for a Closed Case - Hmong F-00363H Word 1/1/2011
Hmong FoodShare Wisconsin Application / Registration - Hmong (PDF, 712 KB) F-16019BH PDF 4/1/2014
Hmong FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) F-16006H PDF 6/1/2013
Hmong FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) F-16066H PDF 10/1/2013
Hmong FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 238 KB) F-16019AH PDF 4/1/2014
Hmong Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H PDF 2/1/2013
Hmong Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) F-10129H PDF 9/1/2013
Hmong Medicaid Change Report - Hmong (PDF, 98 KB) F-10137H PDF 1/1/2014
Hmong Renewal Summary Letter (Hmong) F-00233H Word 4/1/2010
Hmong Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) F-00219H PDF 6/1/2013
Hmong Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H PDF 4/1/2013
Hmong SeniorCare Instructions for Application Form - Hmong (PDF, 128 KB) F-10076AH PDF 9/1/2011
Hmong Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H PDF 7/1/2008
Hmong Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) F-10154H PDF 7/1/2008
Hmong Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) F-10101H PDF 2/1/2013
Russian FoodShare Wisconsin Change Report - Russian (PDF, 305 KB) F-16006R PDF 6/1/2013
Russian FoodShare Wisconsin Income Change Report - Russian (PDF, 211 KB) F-16066R PDF 10/1/2014
Russian FoodShare Wisconsin Registration / Important Information - Russian (PDF, 287 KB) F-16019AR PDF 4/1/2014
Russian Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) F-10154R PDF 7/1/2008
Spanish Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 292 KB) F-14014AS PDF 4/1/2013
Spanish BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) F-10115S PDF 1/1/2011
Spanish BadgerCare Plus Application Packet - Spanish (PDF, 1460 KB) F-10182S PDF 4/1/2014
Spanish BadgerCare Plus Change Report - Spanish (PDF, 340 KB) F-10183S PDF 11/1/2013
Spanish BadgerCare Plus Premium Information / Payment - Spanish (PDF, 37 KB) F-10139S PDF 7/1/2012
Spanish BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) F-00914S PDF 12/1/2013
Spanish Caretaker Supplement (CTS) Instructions for Application - Spanish (PDF, 54 KB) F-22571AS PDF 7/1/2008
Spanish Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) F-10096S PDF 7/1/2008
Spanish Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish (PDF, 33 KB) F-16004S PDF 7/1/2008
Spanish Disaster FoodShare Wisconsin Assistance Application - Spanish (PDF, 75 KB) F-16060S PDF 2/1/2012
Spanish Disqualification Consent Agreement - Spanish (PDF, 72 KB) F-16025S PDF 2/1/2014
Spanish FoodShare and/or Child Care Six Month Report Instructions - Spanish F-16076AS Word 6/1/2014
Spanish FoodShare and/or Child Care Six Month Report - Spanish F-16076S Word 6/1/2014
Spanish FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 41 KB) F-00136S PDF 2/1/2012
Spanish FoodShare Renewal Request for a Closed Case - Spanish F-00363S Word 1/1/2011
Spanish FoodShare Wisconsin Application / Registration - Spanish (PDF, 677 KB) F-16019BS PDF 4/1/2014
Spanish FoodShare Wisconsin Change Report - Spanish (PDF, 133 KB) F-16006S PDF 6/1/2013
Spanish FoodShare Wisconsin Income Change Report - Spanish (PDF, 87 KB) F-16066S PDF 10/1/2013
Spanish FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 299 KB) F-16019AS PDF 4/1/2014
Spanish FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) F-16029S PDF 7/1/2008
Spanish Local Agency Customer Feedback - Spanish (PDF, 29 KB) F-16104S Paper 8/1/2014
Spanish Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S PDF 2/1/2013
Spanish Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) F-10093S PDF 9/1/2013
Spanish Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish (PDF, 35 KB) F-10095S PDF 7/1/2008
Spanish Medicaid Change Report - Spanish (PDF, 65 KB) F-10137S PDF 1/1/2014
Spanish Medicaid Disability Application - Spanish (PDF, 275 KB) F-10112S PDF 3/1/2012
Spanish Medicaid Income Allocation Notice - Spanish (PDF, 49 KB) F-10097S PDF 2/1/2009
Spanish Medicaid Member Asset Allocation Notice - Spanish (PDF, 39 KB) F-10098S PDF 11/1/2013
Spanish Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice - Spanish (PDF, 124 KB) F-10106S PDF 7/1/2008
Spanish Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice - Spanish (PDF, 54 KB) F-10107S PDF 7/1/2008
Spanish Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) F-10129S PDF 9/1/2013
Spanish Negative Notice - Spanish F-16001S Word 7/1/2008
Spanish Negative Notice - Spanish (PDF, 74 KB) F-16001S PDF 7/1/2008
Spanish Notice of Disqualification - Spanish (PDF, 73 KB) F-16024S PDF 2/1/2014
Spanish Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) F-16028S PDF 7/1/2008
Spanish Positive Notice - Spanish F-16015S Word 7/1/2008
Spanish Positive Notice - Spanish (PDF, 46 KB) F-16015S PDF 7/1/2008
Spanish Renewal Summary Letter (Spanish) F-00233S Word 4/1/2010
Spanish Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S PDF 6/1/2013
Spanish Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S PDF 4/1/2013
Spanish SeniorCare Instructions for Application Form - Spanish (PDF, 124 KB) F-10076AS PDF 9/1/2011
Spanish Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S PDF 7/1/2008
Spanish Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) F-10154S PDF 7/1/2008
Spanish Waiver of Administrative Disqualification Hearing - Spanish (PDF, 143 KB) F-16039S PDF 2/1/2014
Spanish Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) F-10101S PDF 2/1/2013
Spanish Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) F-10140S PDF 10/1/2012
Spanish Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) F-10150S PDF 9/1/2013