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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
Medicaid Forms Sorted by Form Type

Last Revised: July 12, 2010

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
PDF Administrative Disqualification Hearing Notice F-16038 10/1/2011 English
PDF Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding F-10145 7/1/2008 English
PDF Agency Position on the Payment Error Rate Measurement (PERM) Error Finding F-10171 7/1/2008 English
PDF Agency Response to the State Quality Assurance (QA) Medicaid Finding F-10172 7/1/2008 English
PDF Authorization to Disclose Information to Disability Determination Bureau (DDB) F-14014 7/1/2008 English
PDF Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish F-14014AS 7/1/2008 Spanish
PDF BadgerCare Plus / Medicaid Health Insurance Information F-10115 1/1/2011 English
PDF BadgerCare Plus / Medicaid Health Insurance Information - Spanish F-10115S 1/1/2011 Spanish
PDF BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 10/1/2008 English
PDF Community Spouse Asset Share Notice F-10096 7/1/2008 English
PDF Community Spouse Asset Share Notice - Spanish F-10096S 7/1/2008 Spanish
PDF Estate Recovery Program (ERP) Disclosure F-13039 7/1/2008 English
PDF Estate Recovery Program (ERP) Disclosure Instructions F-13039A 7/1/2008 English
PDF Financial Records Request F-00407 4/1/2011 English
PDF ForwardHealth Annuity Beneficiary Designation F-10191 1/1/2009 English
PDF ForwardHealth Annuity Information Disclosure F-10192 1/1/2009 English
PDF ForwardHealth Issuer of Annuity - Notice of Obligation F-10190 1/1/2009 English
PDF ForwardHealth Undue Hardship Request F-10193 1/1/2009 English
PDF Good Faith Medicaid / BadgerCare Plus Certification F-10111 2/1/2009 English
PDF Good Faith Medicaid / BadgerCare Plus Certification Instructions F-10111A 2/1/2009 English
PDF Income Maintenance Quality Assurance (IMQA) Web Request F-16083 8/1/2011 English
PDF Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant F-10142 7/1/2008 English
PDF Local Agency Customer Feedback F-16104 11/1/2009 English
PDF Local Agency Customer Feedback - Spanish F-16104S 11/1/2009 Spanish
PDF Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S 7/1/2008 Spanish
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 7/1/2008 English
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong F-10126H 7/1/2008 Hmong
PDF Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish F-10126S 7/1/2008 Spanish
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application F-10129 6/1/2009 English
PDF Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong F-10129H 6/1/2009 Hmong
PDF Medicaid / BadgerCare Plus Fair Hearing Information F-10151 7/1/2008 English
PDF Medicaid / BadgerCare Plus Overpayment Notice F-10093 7/1/2008 English
PDF Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse F-10095 7/1/2008 English
PDF Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish F-10095S 7/1/2008 Spanish
PDF Medicaid Change Report F-10137 7/1/2008 English
PDF Medicaid Change Report - Hmong F-10137H 7/1/2008 Hmong
PDF Medicaid Change Report - Russian F-10137R 7/1/2008 Russian
PDF Medicaid Change Report - Spanish F-10137S 7/1/2008 Spanish
PDF Medicaid Disability Application F-10112 7/1/2008 English
PDF Medicaid Disability Application - Spanish F-10112S 7/1/2008 Spanish
PDF Medicaid Disability Redetermination Report F-10114 7/1/2008 English
PDF Medicaid Income Allocation Notice F-10097 2/1/2009 English
PDF Medicaid Income Allocation Notice - Spanish F-10097S 2/1/2009 Spanish
PDF Medicaid Manual Notice for Cost of Care Contribution F-10108 7/1/2008 English
PDF Medicaid Manual Notice for Cost of Care Contribution Instructions F-10108A 7/1/2008 English
PDF Medicaid Member Asset Allocation Notice F-10098 2/1/2009 English
PDF Medicaid Member Asset Allocation Notice - Spanish F-10098S 2/1/2009 Spanish
PDF Medicaid Presumptive Disability F-10130 8/1/2010 English
PDF Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  F-10127 7/1/2008 English
PDF Medicaid Purchase Plan (MAPP) Independence Account Registration F-10121 9/1/2008 English
PDF Medicaid Purchase Plan (MAPP) Member / Premium Information F-10122 7/1/2008 English
PDF Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  F-13024 7/1/2008 English
PDF Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions F-13023 7/1/2008 English
PDF Medicaid Purchase Plan Premium Information / Payment 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 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 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 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 F-10107S 7/1/2008 Spanish
PDF Medicaid Remaining Deductible Update F-10109 7/1/2008 English
PDF Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish F-10129S 6/1/2009 Spanish
PDF Negative Notice F-16001 7/1/2008 English
PDF Negative Notice - Spanish F-16001S 7/1/2008 Spanish
PDF New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version F-10180 7/1/2008 English
PDF Notice of Program Violation F-16014 7/1/2008 English
PDF Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility F-10099 7/1/2008 English
PDF Positive Notice F-16015 7/1/2008 English
PDF Positive Notice - Spanish F-16015S 7/1/2008 Spanish
PDF Self-Employment Income Report F-00107 5/1/2010 English
PDF Self-Employment Income Report (Worksheet) F-00107W 5/1/2010 English
PDF Self-Employment Income Report - Farmer F-00219 5/1/2010 English
PDF Self-Employment Income Report - Farmer (Worksheet) F-00219W 5/1/2010 English
PDF Self-Employment Income Report - Farmer - Hmong F-00219H 5/1/2010 Hmong
PDF Self-Employment Income Report - Farmer - Spanish F-00219S 5/1/2010 Spanish
PDF Self-Employment Income Report - Hmong F-00107H 5/1/2010 Hmong
PDF Self-Employment Income Report - Spanish F-00107S 5/1/2010 Spanish
PDF Self-Employment Income Worksheet - Corporation F-16034 2/1/2010 English
PDF Self-Employment Income Worksheet - Partnership F-16036 5/1/2009 English
PDF Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 5/1/2009 English
PDF Self-Employment Income Worksheet - Subchapter S Corporation F-16035 5/1/2009 English
PDF Social Security Number Referral F-16022 7/1/2008 English
PDF Social Security Number Referral - Hmong F-16022H 7/1/2008 Hmong
PDF Social Security Number Referral - Spanish F-16022S 7/1/2008 Spanish
PDF Statement of Citizenship and / or Identity for Special Populations F-10161 7/1/2008 English
PDF Statement of Identity for Children Under 18 Years of Age F-10154 7/1/2008 English
PDF Statement of Identity for Children Under 18 Years of Age - Hmong F-10154H 7/1/2008 Hmong
PDF Statement of Identity for Children Under 18 Years of Age - Russian F-10154R 7/1/2008 Russian
PDF Statement of Identity for Children Under 18 Years of Age - Spanish F-10154S 7/1/2008 Spanish
PDF Statement of Identity for Persons in Institutional Care Facilities F-10175 7/1/2008 English
PDF Student Aid and Expense Worksheet F-16031 7/1/2008 English
PDF Student Financial Report F-16021 7/1/2008 English
PDF Unprocessed Family Care, Pace, or Partnership Disenrollment Request F-00009 12/1/2008 English
PDF Verification of Veterans Benefits F-10162 7/1/2008 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice F-10143 1/1/2011 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 1/1/2011 English
PDF Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A 1/1/2011 English
PDF Wisconsin Medicaid for the Elderly, Blind or Disabled Application / Review Packet - Hmong F-10101H 3/1/2010 Hmong
PDF Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet F-10101 6/1/2011 English
PDF Wisconsin Medicaid Health Care for the Elderly, Blind and Disabled Application / Review Packet - Spanish F-10101S 3/1/2010 Spanish
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 7/1/2008 English
PDF Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish F-10140S 7/1/2008 Spanish
PDF Wisconsin Veterans Home at King - Medicaid Review F-10147 7/1/2008 English
PDF Wisconsin Well Woman Medicaid Determination F-10075 12/1/2009 English
PDF Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin F-10150 7/1/2008 English
PDF Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin - Spanish F-10150S 7/1/2008 Spanish
System Medicaid / BadgerCare Plus Certification F-10110 11/1/2008 English
Word Authorization to Request Birth Records F-00101 6/1/2009 English
Word BadgerCare Plus Express Enrollment Change Request for Partners / Providers F-10176 10/1/2008 English
Word Employment Verification of Earnings F-10146 7/1/2008 English
Word Enrollment Services Center State Vital Records Letter F-00100E 6/1/2009 English
Word ForwardHealth Divestment Penalty and Undue Hardship Notice F-10187 1/1/2009 English
Word ForwardHealth Undue Hardship Bedhold Notice F-10189 1/1/2009 English
Word ForwardHealth Undue Hardship Waiver Decision F-10188 1/1/2009 English
Word Life Insurance Inquiry F-10144 7/1/2008 English
Word Negative Notice F-16001 7/1/2008 English
Word Positive Notice F-16015 7/1/2008 English
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
Word Summary of Information Letter F-00098 6/1/2009 English