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Eligibility Management (Income Maintenance) Home >> IM Forms

Medicaid Forms Sorted by Language

Last Revised: March 26, 2014

This list contains all Medicaid forms that are available from DHCAA 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
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 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 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 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 Financial Records Request (PDF, 28 KB) F-00407 PDF 4/1/2011
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 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 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 Renewal Summary Letter F-00233 Word 4/1/2010
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 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 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 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 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 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 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 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 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 Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) F-10096S 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 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 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 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