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Eligibility Management (Income Maintenance) Home >> IM Forms

Medicaid Forms Sorted by Form Type

Last Revised: March 26, 2014

This list contains all Medicaid 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 Local Agency Customer Feedback (PDF, 17 KB) F-16104 11/1/2009 English
Paper Local Agency Customer Feedback - Spanish (PDF, 16 KB) F-16104S 11/1/2009 Spanish
Paper Medicaid Change Report (PDF, 88 KB) F-10137 1/1/2014 English
Paper Medicaid Disability Application (PDF, 1982 KB) F-10112 3/1/2012 English
Paper Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) F-10101 2/1/2013 English
Paper Wisconsin Well Woman Medicaid Determination (PDF, 78 KB) F-10075 1/1/2014 English
PDF Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding (PDF, 25 KB) F-10145 7/1/2008 English
PDF Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) F-10171 7/1/2008 English
PDF Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) F-10172 7/1/2008 English
PDF Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF, 199 KB) F-14014 4/1/2013 English
PDF Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 292 KB) F-14014AS 4/1/2013 Spanish
PDF BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) F-10115 1/1/2011 English
PDF BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) F-10115S 1/1/2011 Spanish
PDF Community Spouse Asset Share Notice (PDF, 658 KB) F-10096 7/1/2008 English
PDF Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) F-10096S 7/1/2008 Spanish
PDF Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) F-00628 7/1/2012 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 Financial Records Request (PDF, 28 KB) F-00407 4/1/2011 English
PDF Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) F-10111 9/1/2013 English
PDF Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) F-10111A 9/1/2013 English
PDF Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 8/1/2011 English
PDF Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF, 107 KB) F-10142 7/1/2008 English
PDF Local Agency Customer Feedback (PDF, 17 KB) F-16104H 11/1/2009 English
PDF Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) F-10191 1/1/2009 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) F-10126 2/1/2013 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H 2/1/2013 Hmong
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S 2/1/2013 Spanish
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) F-10129 9/1/2013 English
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) F-10129H 9/1/2013 Hmong
PDF Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) F-10151 7/1/2008 English
PDF Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) F-10109 2/1/2014 English
PDF Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) F-10093S 9/1/2013 Spanish
PDF Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) F-10093 9/1/2013 English
PDF Medicaid Annuity Information - Disclosure (PDF, 2.1 MB) F-10192 1/1/2009 English
PDF Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (PDF, 395 KB) F-10095 7/1/2008 English
PDF Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish (PDF, 35 KB) F-10095S 7/1/2008 Spanish
PDF Medicaid Change Report - Hmong (PDF, 98 KB) F-10137H 1/1/2014 Hmong
PDF Medicaid Change Report - Spanish (PDF, 65 KB) F-10137S 1/1/2014 Spanish
PDF Medicaid Disability Application - Spanish (PDF, 275 KB) F-10112S 3/1/2012 Spanish
PDF Medicaid Disability Redetermination Report (PDF, 222 KB) F-10114 2/1/2013 English
PDF Medicaid Income Allocation Notice (PDF, 44 KB) F-10097 2/1/2009 English
PDF Medicaid Income Allocation Notice - Spanish (PDF, 49 KB) F-10097S 2/1/2009 Spanish
PDF Medicaid Issuer of Annuity - Notice of Obligation (PDF, 641 KB) F-10190 1/1/2009 English
PDF Medicaid Manual Notice for Cost of Care Contribution (PDF, 168 KB) F-10108 7/1/2008 English
PDF Medicaid Manual Notice for Cost of Care Contribution Instructions (PDF, 509 KB) F-10108A 7/1/2008 English
PDF Medicaid Member Asset Allocation Notice (PDF, 85 KB) F-10098 11/1/2013 English
PDF Medicaid Member Asset Allocation Notice - Spanish (PDF, 39 KB) F-10098S 11/1/2013 Spanish
PDF Medicaid Presumptive Disability (PDF, 51 KB) F-10130 4/1/2012 English
PDF Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) F-10127 7/1/2008 English
PDF Medicaid Purchase Plan (MAPP) Independence Account Registration (PDF, 29 KB) F-10121 9/1/2008 English
PDF Medicaid Purchase Plan (MAPP) Member / Premium Information (PDF, 117 KB) F-10122 7/1/2008 English
PDF Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions (PDF, 1.4 MB) F-13024 7/1/2008 English
PDF Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions (PDF, 1.3 MB) F-13023 7/1/2008 English
PDF Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) F-00332 11/1/2010 English
PDF 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 7/1/2008 Spanish
PDF 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 7/1/2008 English
PDF 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 7/1/2008 English
PDF 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 7/1/2008 Spanish
PDF Medicaid Undue Hardship Request (PDF, 2.7 MB) F-10193 1/1/2009 English
PDF Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) F-10129S 9/1/2013 Spanish
PDF Negative Notice (PDF, 154 KB) F-16001 7/1/2008 English
PDF Negative Notice - Spanish (PDF, 74 KB) F-16001S 7/1/2008 Spanish
PDF New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) F-10180 7/1/2008 English
PDF Notice of Program Violation (PDF, 43 KB) F-16014 7/1/2008 English
PDF Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB) F-10099 7/1/2008 English
PDF Positive Notice (PDF, 134 KB) F-16015 7/1/2008 English
PDF Positive Notice - Spanish (PDF, 46 KB) F-16015S 7/1/2008 Spanish
PDF Self-Employment Income Report (PDF, 91 KB) F-00107 5/1/2013 English
PDF Self-Employment Income Report (Worksheet) (PDF, 32 KB) F-00107W 5/1/2010 English
PDF Self-Employment Income Report - Farmer (PDF, 74 KB) F-00219 6/1/2013 English
PDF Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) F-00219W 5/1/2010 English
PDF Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) F-00219H 6/1/2013 Hmong
PDF Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S 6/1/2013 Spanish
PDF Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H 4/1/2013 Hmong
PDF Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S 4/1/2013 Spanish
PDF Self-Employment Income Worksheet - Corporation (PDF, 25 KB) F-16034 2/1/2014 English
PDF Self-Employment Income Worksheet - Partnership (PDF, 27 KB) F-16036 2/1/2014 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) F-16037 2/1/2014 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) F-16037A 6/1/2014 English
PDF Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) F-16035 2/1/2014 English
PDF Social Security Number Referral (PDF, 61 KB) F-16022 7/1/2008 English
PDF Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H 7/1/2008 Hmong
PDF Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S 7/1/2008 Spanish
PDF Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) F-10161 7/1/2008 English
PDF Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) F-10154 7/1/2008 English
PDF Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) F-10154H 7/1/2008 Hmong
PDF Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) F-10154R 7/1/2008 Russian
PDF Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) F-10154S 7/1/2008 Spanish
PDF Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) F-10175 9/1/2013 English
PDF Statement of Tribal Affiliation (PDF, 24 KB) F-00685 11/1/2012 English
PDF Student Aid and Expense Worksheet (PDF, 256 KB) F-16031 7/1/2008 English
PDF Student Financial Report (PDF, 194 KB) F-16021 7/1/2008 English
PDF Summary of Information Letter (PDF, 224 KB) F-00098 6/1/2009 English
PDF Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) F-00009 12/1/2008 English
PDF Verification of Veterans Benefits (PDF, 53 KB) F-10162 1/1/2014 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) F-10143 11/1/2013 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) F-10141 11/1/2013 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
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) F-10140 10/1/2012 English
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) F-10140S 10/1/2012 Spanish
PDF Wisconsin Veterans Home at King - Medicaid Review (PDF, 253 KB) F-10147 7/1/2008 English
PDF Your Rights and Responsibilities for Health Care (PDF, 56 KB) F-10150A 10/1/2012 English
PDF Your Rights and Responsibilities for Health Care - Spanish (PDF, 56 KB) F-10150AS 10/1/2012 English
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) F-10150S 9/1/2013 Spanish
PDF Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 9/1/2013 English
System Medicaid / BadgerCare Plus Certification F-10110 4/1/2011 English
System Medicaid / BadgerCare Plus Certification Instructions F-10110A 4/1/2011 English
Word Authorization to Request Birth Records F-00101 6/1/2009 English
Word Consortium Response to the State IM Second Party Review Finding F-00628 7/1/2012 English
Word Employment Verification of Earnings F-10146 7/1/2008 English
Word Life Insurance Inquiry F-10144 7/1/2008 English
Word Medicaid and BadgerCare Plus Overpayment Notice F-10093 9/1/2013 English
Word Medicaid and BadgerCare Plus Overpayment Notice - Spanish F-10093S 9/1/2013 English
Word Medicaid Divestment Penalty and Undue Hardship Notice F-10187 1/1/2009 English
Word Medicaid Undue Hardship Bedhold Notice F-10189 1/1/2009 English
Word Medicaid Undue Hardship Waiver Decision F-10188 1/1/2009 English
Word Negative Notice F-16001 7/1/2008 English
Word Negative Notice - Spanish F-16001S 7/1/2008 Spanish
Word Positive Notice F-16015 7/1/2008 English
Word Positive Notice - Spanish F-16015S 7/1/2008 Spanish
Word Renewal Summary Letter F-00233 4/1/2010 English
Word Renewal Summary Letter (Hmong) F-00233H 4/1/2010 Hmong
Word Renewal Summary Letter (Spanish) F-00233S 4/1/2010 Spanish
Word State Vital Records Cover Letter F-00100 6/1/2009 English