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Eligibility Management (Income Maintenance) Home >> IM Forms

Medicaid Forms Sorted by Form Title

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 Title Form Number Form Type Revised Date Language 
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 Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 292 KB) F-14014AS PDF 4/1/2013 Spanish
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 / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) F-10115S PDF 1/1/2011 Spanish
Community Spouse Asset Share Notice (PDF, 658 KB) F-10096 PDF 7/1/2008 English
Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) F-10096S PDF 7/1/2008 Spanish
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 7/1/2008 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
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 (PDF, 17 KB) F-16104 Paper 11/1/2009 English
Local Agency Customer Feedback (PDF, 17 KB) F-16104H PDF 11/1/2009 English
Local Agency Customer Feedback - Spanish (PDF, 16 KB) F-16104S Paper 11/1/2009 Spanish
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 / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) F-10126H PDF 2/1/2013 Hmong
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) F-10126S PDF 2/1/2013 Spanish
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) F-10129 PDF 9/1/2013 English
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) F-10129H PDF 9/1/2013 Hmong
Medicaid / BadgerCare Plus Certification F-10110 System 11/1/2008 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 Overpayment Notice - Spanish (PDF, 59 KB) F-10093S PDF 9/1/2013 Spanish
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 Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish (PDF, 35 KB) F-10095S PDF 7/1/2008 Spanish
Medicaid Change Report (PDF, 88 KB) F-10137 Paper 1/1/2014 English
Medicaid Change Report - Hmong (PDF, 98 KB) F-10137H PDF 1/1/2014 Hmong
Medicaid Change Report - Spanish (PDF, 65 KB) F-10137S PDF 1/1/2014 Spanish
Medicaid Disability Application (PDF, 1982 KB) F-10112 Paper 3/1/2012 English
Medicaid Disability Application - Spanish (PDF, 275 KB) F-10112S PDF 3/1/2012 Spanish
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 Income Allocation Notice - Spanish (PDF, 49 KB) F-10097S PDF 2/1/2009 Spanish
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 Member Asset Allocation Notice - Spanish (PDF, 39 KB) F-10098S PDF 2/1/2009 Spanish
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 - 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+) 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 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 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
Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) F-10129S PDF 9/1/2013 Spanish
Negative Notice F-16001 Word 7/1/2008 English
Negative Notice (PDF, 154 KB) F-16001 PDF 7/1/2008 English
Negative Notice - Spanish F-16001S Word 7/1/2008 Spanish
Negative Notice - Spanish (PDF, 200 KB) F-16001S PDF 7/1/2008 Spanish
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
Positive Notice - Spanish (PDF, 46 KB) F-16015S PDF 7/1/2008 Spanish
Renewal Summary Letter F-00233 Word 4/1/2010 English
Renewal Summary Letter (Hmong) F-00233H Word 4/1/2010 Hmong
Renewal Summary Letter (Spanish) F-00233S Word 4/1/2010 Spanish
Self-Employment Income Report (PDF, 47 KB) F-00107 PDF 4/1/2013 English
Self-Employment Income Report (Worksheet) (PDF, 32 KB) F-00107W PDF 5/1/2010 English
Self-Employment Income Report - Farmer (PDF, 74 KB) F-00219 PDF 6/1/2013 English
Self-Employment Income Report - Farmer (Worksheet) (PDF, 32 KB) F-00219W PDF 5/1/2010 English
Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) F-00219H PDF 6/1/2013 Hmong
Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) F-00219S PDF 6/1/2013 Spanish
Self-Employment Income Report - Hmong (PDF, 51 KB) F-00107H PDF 4/1/2013 Hmong
Self-Employment Income Report - Spanish (PDF, 52 KB) F-00107S PDF 4/1/2013 Spanish
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, 25 KB) F-16037A PDF 2/1/2014 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
Social Security Number Referral - Hmong (PDF, 28 KB) F-16022H PDF 7/1/2008 Hmong
Social Security Number Referral - Spanish (PDF, 26 KB) F-16022S PDF 7/1/2008 Spanish
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 Children Under 18 Years of Age - Hmong (PDF, 33 KB) F-10154H PDF 7/1/2008 Hmong
Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) F-10154R PDF 7/1/2008 Russian
Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) F-10154S PDF 7/1/2008 Spanish
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 F-00098 Word 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 - Spanish(PDF,704 KB) F-10101S PDF 2/1/2013 Spanish
Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) F-10101 Paper 2/1/2013 English
Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) F-10101H PDF 2/1/2013 Hmong
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) F-10140 PDF 10/1/2012 English
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) F-10140S PDF 10/1/2012 Spanish
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, 71 KB) F-10150S PDF 9/1/2013 Spanish
Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) F-10150 PDF 9/1/2013 English