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Eligibility Management (Income Maintenance) Home >> IM Forms

Medicaid Forms Sorted by Form Number

Last Revised: March 26, 2014

This list contains all Medicaid 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 Number Form Title Form Type Revised Date Language
F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) PDF 12/1/2008 English
F-00098 Summary of Information Letter Word 6/1/2009 English
F-00100 State Vital Records Cover Letter Word 6/1/2009 English
F-00101 Authorization to Request Birth Records Word 6/1/2009 English
F-00107 Self-Employment Income Report (PDF, 47 KB) PDF 4/1/2013 English
F-00107H Self-Employment Income Report - Hmong (PDF, 51 KB) PDF 4/1/2013 Hmong
F-00107S Self-Employment Income Report - Spanish (PDF, 52 KB) PDF 4/1/2013 Spanish
F-00107W Self-Employment Income Report (Worksheet) (PDF, 32 KB) PDF 5/1/2010 English
F-00219 Self-Employment Income Report - Farmer (PDF, 74 KB) PDF 6/1/2013 English
F-00219H Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) PDF 6/1/2013 Hmong
F-00219S Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) PDF 6/1/2013 Spanish
F-00219W Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) PDF 5/1/2010 English
F-00233 Renewal Summary Letter Word 4/1/2010 English
F-00233H Renewal Summary Letter (Hmong) Word 4/1/2010 Hmong
F-00233S Renewal Summary Letter (Spanish) Word 4/1/2010 Spanish
F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) PDF 11/1/2010 English
F-00407 Financial Records Request (PDF, 28 KB) PDF 4/1/2011 English
F-00628 Consortium Response to the State IM Second Party Review Finding Word 7/1/2012 English
F-00628 Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) PDF 7/1/2012 English
F-00685 Statement of Tribal Affiliation (PDF, 24 KB) PDF 11/1/2012 English
F-10075 Wisconsin Well Woman Medicaid Determination (PDF, 78 KB) Paper 1/1/2014 English
F-10093 Medicaid and BadgerCare Plus Overpayment Notice Word 9/1/2013 English
F-10093 Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) PDF 9/1/2013 English
F-10093S Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) PDF 9/1/2013 Spanish
F-10093S Medicaid and BadgerCare Plus Overpayment Notice - Spanish Word 9/1/2013 English
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (PDF, 395 KB) PDF 7/1/2008 English
F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish (PDF, 35 KB) PDF 7/1/2008 Spanish
F-10096 Community Spouse Asset Share Notice (PDF, 658 KB) PDF 7/1/2008 English
F-10096S Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) PDF 7/1/2008 Spanish
F-10097 Medicaid Income Allocation Notice (PDF, 44 KB) PDF 2/1/2009 English
F-10097S Medicaid Income Allocation Notice - Spanish (PDF, 49 KB) PDF 2/1/2009 Spanish
F-10098 Medicaid Member Asset Allocation Notice (PDF, 85 KB) PDF 11/1/2013 English
F-10098S Medicaid Member Asset Allocation Notice - Spanish (PDF, 39 KB) PDF 2/1/2009 Spanish
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB) PDF 7/1/2008 English
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) Paper 2/1/2013 English
F-10101H Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) PDF 2/1/2013 Hmong
F-10101S Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) PDF 2/1/2013 Spanish
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice (PDF, 342 KB) PDF 7/1/2008 English
F-10106S 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) PDF 7/1/2008 Spanish
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice (PDF, 477 KB) PDF 7/1/2008 English
F-10107S 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) PDF 7/1/2008 Spanish
F-10108 Medicaid Manual Notice for Cost of Care Contribution (PDF, 168 KB) PDF 7/1/2008 English
F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions (PDF, 509 KB) PDF 7/1/2008 English
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) PDF 2/1/2014 English
F-10110 Medicaid / BadgerCare Plus Certification System 11/1/2008 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) PDF 9/1/2013 English
F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) PDF 9/1/2013 English
F-10112 Medicaid Disability Application (PDF, 1982 KB) Paper 3/1/2012 English
F-10112S Medicaid Disability Application - Spanish (PDF, 275 KB) PDF 3/1/2012 Spanish
F-10114 Medicaid Disability Redetermination Report (PDF, 222 KB) PDF 2/1/2013 English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) PDF 1/1/2011 English
F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) PDF 1/1/2011 Spanish
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration (PDF, 29 KB) PDF 9/1/2008 English
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information (PDF, 117 KB) PDF 7/1/2008 English
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) PDF 2/1/2013 English
F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) PDF 2/1/2013 Hmong
F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) PDF 2/1/2013 Spanish
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) PDF 7/1/2008 English
F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) PDF 9/1/2013 English
F-10129H Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) PDF 9/1/2013 Hmong
F-10129S Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) PDF 9/1/2013 Spanish
F-10130 Medicaid Presumptive Disability (PDF, 51 KB) PDF 4/1/2012 English
F-10137 Medicaid Change Report (PDF, 88 KB) Paper 1/1/2014 English
F-10137H Medicaid Change Report - Hmong (PDF, 98 KB) PDF 1/1/2014 Hmong
F-10137S Medicaid Change Report - Spanish (PDF, 65 KB) PDF 1/1/2014 Spanish
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) PDF 10/1/2012 English
F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) PDF 10/1/2012 Spanish
F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) PDF 11/1/2013 English
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF, 107 KB) PDF 7/1/2008 English
F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) PDF 11/1/2013 English
F-10144 Life Insurance Inquiry Word 7/1/2008 English
F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding (PDF, 25 KB) PDF 7/1/2008 English
F-10146 Employment Verification of Earnings Word 7/1/2008 English
F-10147 Wisconsin Veterans Home at King - Medicaid Review (PDF, 253 KB) PDF 7/1/2008 English
F-10150 Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) PDF 9/1/2013 English
F-10150A Your Rights and Responsibilities for Health Care (PDF, 56 KB) PDF 10/1/2012 English
F-10150AS Your Rights and Responsibilities for Health Care - Spanish (PDF, 56 KB) PDF 10/1/2012 English
F-10150S Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) PDF 9/1/2013 Spanish
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) PDF 7/1/2008 English
F-10154 Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) PDF 7/1/2008 English
F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) PDF 7/1/2008 Hmong
F-10154R Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) PDF 7/1/2008 Russian
F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) PDF 7/1/2008 Spanish
F-10161 Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) PDF 7/1/2008 English
F-10162 Verification of Veterans Benefits (PDF, 53 KB) PDF 1/1/2014 English
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) PDF 7/1/2008 English
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) PDF 7/1/2008 English
F-10175 Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) PDF 9/1/2013 English
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) PDF 7/1/2008 English
F-10187 Medicaid Divestment Penalty and Undue Hardship Notice Word 1/1/2009 English
F-10188 Medicaid Undue Hardship Waiver Decision Word 1/1/2009 English
F-10189 Medicaid Undue Hardship Bedhold Notice Word 1/1/2009 English
F-10190 Medicaid Issuer of Annuity - Notice of Obligation (PDF, 641 KB) PDF 1/1/2009 English
F-10191 Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) PDF 1/1/2009 English
F-10192 Medicaid Annuity Information - Disclosure (PDF, 2.1 MB) PDF 1/1/2009 English
F-10193 Medicaid Undue Hardship Request (PDF, 2.7 MB) PDF 1/1/2009 English
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions (PDF, 1.3 MB) PDF 7/1/2008 English
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions (PDF, 1.4 MB) PDF 7/1/2008 English
F-13039 Estate Recovery Program (ERP) Disclosure (PDF, 30 KB) PDF 7/1/2008 English
F-13039A Estate Recovery Program (ERP) Disclosure Instructions (PDF, 20 KB) PDF 7/1/2008 English
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF, 199 KB) PDF 4/1/2013 English
F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 292 KB) PDF 4/1/2013 Spanish
F-16001 Negative Notice Word 7/1/2008 English
F-16001 Negative Notice (PDF, 154 KB) PDF 7/1/2008 English
F-16001S Negative Notice - Spanish Word 7/1/2008 Spanish
F-16001S Negative Notice - Spanish (PDF, 200 KB) PDF 7/1/2008 Spanish
F-16014 Notice of Program Violation (PDF, 43 KB) PDF 7/1/2008 English
F-16015 Positive Notice Word 7/1/2008 English
F-16015 Positive Notice (PDF, 134 KB) PDF 7/1/2008 English
F-16015S Positive Notice - Spanish (PDF, 46 KB) PDF 7/1/2008 Spanish
F-16021 Student Financial Report (PDF, 194 KB) PDF 7/1/2008 English
F-16022 Social Security Number Referral (PDF, 61 KB) PDF 7/1/2008 English
F-16022H Social Security Number Referral - Hmong (PDF, 28 KB) PDF 7/1/2008 Hmong
F-16022S Social Security Number Referral - Spanish (PDF, 26 KB) PDF 7/1/2008 Spanish
F-16031 Student Aid and Expense Worksheet (PDF, 256 KB) PDF 7/1/2008 English
F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) PDF 2/1/2014 English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) PDF 2/1/2014 English
F-16036 Self-Employment Income Worksheet - Partnership (PDF, 27 KB) PDF 2/1/2014 English
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) PDF 2/1/2014 English
F-16037A Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 25 KB) PDF 2/1/2014 English
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) PDF 8/1/2011 English
F-16104 Local Agency Customer Feedback (PDF, 17 KB) Paper 11/1/2009 English
F-16104H Local Agency Customer Feedback (PDF, 17 KB) PDF 11/1/2009 English
F-16104S Local Agency Customer Feedback - Spanish (PDF, 16 KB) Paper 11/1/2009 Spanish