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Forms: Numeric List - DHCAA
Division of Health Care Access and Accountability

This numeric list contains forms that are available from this site.  A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms. Microsoft Word - Fillable or Excel forms, 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.

Key word explanations for Form Type and Other Location columns.

Division Prefix Assigned Form Number Form Title Form Type Other Location Language
DHCAA F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) PDF None English
DHCAA F-00020 Drug Addition Review Request (PDF, 653 KB) PDF None English
DHCAA F-00020 Drug Addition Review Request Word None English
DHCAA F-00021 HealthCheck Referral (PDF, 18 KB) PDF None English
DHCAA F-00023 Case Management Agency Self-Audit Checklist (PDF, 191 KB) PDF None English
DHCAA F-00030 State Maximum Allowed Cost Drug Pricing Review Request (PDF, 1316 KB) PDF None English
DHCAA F-00030 State Maximum Allowed Cost Drug Pricing Review Request Word None English
DHCAA F-00030A State Maximum Allowed Cost Drug Pricing Review Request Completion Instructions (PDF, 35 KB) PDF None English
DHCAA F-00079 Prior Authorization / Drug Attachment for Modafinil and Nuvigil (PDF, 2902 KB) PDF None English
DHCAA F-00079 Prior Authorization / Drug Attachment for Modafinil and Nuvigil Word None English
DHCAA F-00079A Prior Authorization / Drug Attachment for Modafinil and Nuvigil Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-00080 Prior Authorization / Preferred Drug List (PA/PDL) for Symlin (PDF, 51 KB) PDF None English
DHCAA F-00080 Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Word None English
DHCAA F-00080A Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Completion Instructions (PDF, 48 KB) PDF None English
DHCAA F-00081 Prior Authorization / Drug Attachment for Suboxone and Buprenorphine (PDF, 1376 KB) PDF None English
DHCAA F-00081 Prior Authorization / Drug Attachment for Suboxone and Buprenorphine Word None English
DHCAA F-00081A Prior Authorization / Drug Attachment for Suboxone and Buprenorphine Completion Instructions (PDF, 34 KB) PDF None English
DHCAA F-00098 Summary of Information Letter (PDF, 224 KB) PDF None English
DHCAA F-00100 State Vital Records Cover Letter Word None English
DHCAA F-00101 Authorization to Request Birth Records Word None English
DHCAA F-00107 Self-Employment Income Report (PDF, 91 KB) PDF None English
DHCAA F-00107H Self-Employment Income Report - Hmong (PDF, 51 KB) PDF None Hmong
DHCAA F-00107S Self-Employment Income Report - Spanish (PDF, 52 KB) PDF None Spanish
DHCAA F-00107W Self-Employment Income Report (Worksheet) (PDF, 37 KB) PDF None English
DHCAA F-00136 FoodShare Employment and Training (FSET) Participation Agreement (PDF, 368 KB) PDF None English
DHCAA F-00136H FoodShare Employment and Training (FSET) Participation Agreement - Hmong (PDF, 42 KB) PDF None Hmong
DHCAA F-00136S FoodShare Employment and Training (FSET) Participation Agreement - Spanish (PDF, 41 KB) PDF None Spanish
DHCAA F-00142 Prior Authorization / Drug Attachment for Synagis (PDF, 2939 KB) PDF None English
DHCAA F-00142 Prior Authorization / Drug Attachment for Synagis Word None English
DHCAA F-00142A Prior Authorization / Drug Attachment for Synagis Completion Instructions (PDF, 49 KB) PDF None English
DHCAA F-00154 Wisconsin Consultative Examination Inquiry Word None English
DHCAA F-00162 Prior Authorization / Drug Attachment for Lipotropics, Omega-3 Acids (PDF, 1315 KB) PDF None English
DHCAA F-00162 Prior Authorization / Drug Attachment for Lovaza Word None English
DHCAA F-00162A Prior Authorization / Drug Attachment for Lovaza Completion Instructions (PDF, 61 KB) PDF None English
DHCAA F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs (PDF, 1382 KB) PDF None English
DHCAA F-00163 Prior Authorization / Drug Attachment for Anti-Obesity Drugs Word None English
DHCAA F-00163A Prior Authorization / Drug Attachment for Anti-Obesity Drugs Completion Instructions (PDF, 65 KB) PDF None English
DHCAA F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids (PDF, 1324 KB) PDF None English
DHCAA F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids Word None English
DHCAA F-00194A Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids Completion Instructions (PDF, 42 KB) PDF None English
DHCAA F-00219 Self-Employment Income Report - Farmer (PDF, 74 KB) PDF None English
DHCAA F-00219H Self-Employment Income Report - Farmer - Hmong (PDF, 82 KB) PDF None Hmong
DHCAA F-00219S Self-Employment Income Report - Farmer - Spanish (PDF, 77 KB) PDF None Spanish
DHCAA F-00219W Self-Employment Income Report - Farmer (Worksheet) (PDF, 37 KB) PDF None English
DHCAA F-00233 Renewal Summary Letter Word None English
DHCAA F-00233H Renewal Summary Letter (Hmong) Word None Hmong
DHCAA F-00233S Renewal Summary Letter (Spanish) Word None Spanish
DHCAA F-00238 Prior Authorization / Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents (PDF, 138 KB) PDF None English
DHCAA F-00238 Prior Authorization / Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents Word None English
DHCAA F-00238A Prior Authorization / Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents Completion Instructions (PDF, 88 KB) PDF None English
DHCAA F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips (PDF, 1400 KB) PDF None English
DHCAA F-00239 Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips Word None English
DHCAA F-00239A Prior Authorization / Drug Attachment for Blood Glucose Meters and Test Strips Completion Instructions (PDF, 43 KB) PDF None English
DHCAA F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) PDF None English
DHCAA F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use (PDF, 57 KB) PDF None English
DHCAA F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use Word None English
DHCAA F-00280 Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents (PDF, 1396 KB) PDF None English
DHCAA F-00280 Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents Word None English
DHCAA F-00280A Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents Completion Instructions (PDF, 31 KB) PDF None English
DHCAA F-00281 Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents (PDF, 1315 KB) PDF None English
DHCAA F-00281 Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents Word None English
DHCAA F-00281A Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents Completion Instructions (PDF, 31 KB) PDF None English
DHCAA F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections (PDF, 1149 KB) PDF None English
DHCAA F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Word None English
DHCAA F-00286A Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections Completion Instructions (PDF, 30 KB) PDF None English
DHCAA F-00330 Request for Replacement FoodShare Benefits (PDF, 28 KB) PDF None English
DHCAA F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) PDF None English
DHCAA F-00343 Eligibility Management (Income Maintenance) Policy Notification Sign-Up HTML None English
DHCAA F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services (PDF, 21 KB) PDF None English
DHCAA F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services Word None English
DHCAA F-00356 Family Planning Only Services Authorization for Electronic Data Transfer of Application (PDF, 25 KB) PDF None English
DHCAA F-00363 FoodShare Renewal Request for a Closed Case Word None English
DHCAA F-00363H FoodShare Renewal Request for a Closed Case - Hmong Word None Hmong
DHCAA F-00363S FoodShare Renewal Request for a Closed Case - Spanish Word None Spanish
DHCAA F-00401 Expedited Emergency Supply Request (PDF, 35 KB) PDF None English
DHCAA F-00401 Expedited Emergency Supply Request Word None English
DHCAA F-00401A Expedited Emergency Supply Request Completion Instructions (PDF, 58 KB) PDF None English
DHCAA F-00407 Financial Records Request (PDF, 28 KB) PDF None English
DHCAA F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tablets (PDF, 132 KB) PDF None English
DHCAA F-00433 Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tablets Word None English
DHCAA F-00433A Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tablets Completion Instructions (PDF, 33 KB) PDF None English
DHCAA F-00476 CARES Automated Systems Access Request Word None English
DHCAA F-00476A CARES Automated Systems Access Request Completion Instructions (PDF, 31 KB) PDF None English
DHCAA F-00556 Prior Authorization - Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age or Younger (PDF, 2009 KB) PDF None English
DHCAA F-00556 Prior Authorization - Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age or Younger Word None English
DHCAA F-00556A Prior Authorization - Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age or Younger Completion Instructions (PDF, 88 KB) PDF None English
DHCAA F-00583 Prior Authorization - Drug Attachment for Hepatitis C Protease Inhibitors (PDF, 586 KB) PDF None English
DHCAA F-00583 Prior Authorization - Drug Attachment for Hepatitis C Protease Inhibitors Word None English
DHCAA F-00583A Prior Authorization - Drug Attachment for Hepatitis C Protease Inhibitors Completion Instructions (PDF, 39 KB) PDF None English
DHCAA F-00628 Consortium Response to the State IM Second Party Review Finding (PDF, 25 KB) PDF None English
DHCAA F-00628 Consortium Response to the State IM Second Party Review Finding Word None English
DHCAA F-00639 Agency Data Security Staff User Agreement Word None English
DHCAA F-00685 Statement of Tribal Affiliation (PDF, 24 KB) PDF None English
DHCAA F-00694 Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis (PDF, 604 KB) PDF None English
DHCAA F-00694 Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis Word None English
DHCAA F-00694A Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis Completion Instructions (PDF, 60 KB) PDF None English
DHCAA F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) (PDF, 141 KB) PDF None English
DHCAA F-00701 Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) Word None English
DHCAA F-00701A Prior Authorization - Drug Attachment for Onabotulinumtoxin A (Botox) Completion Instructions (PDF, 40 KB) PDF None English
DHCAA F-00704 Prior Authorization - Committee Public Testimony Registration (PDF, 29 KB) PDF None English
DHCAA F-00787 Prior Authorization - Exemption Request for CT and MR Imaging Services (PDF, 23 KB) PDF None English
DHCAA F-00787 Prior Authorization - Exemption Request for CT and MR Imaging Services Word None English
DHCAA F-00805 Prior Authorization - Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators (PDF, 49 KB) PDF None English
DHCAA F-00805 Prior Authorization - Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators Word None English
DHCAA F-00805A Prior Authorization - Preferred Drug List (PA/PDL) for Multiple Sclerosis (MS) Agents, Immunomodulators Completion Instructions (PDF, 46 KB) PDF None English
DHCAA F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy (PDF, 91 KB) PDF None English
DHCAA F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Word None English
DHCAA F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member (PDF, 1.3 MB) PDF None English
DHCAA F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member Word None English
DHCAA F-00842 Pharmacy Services Lock-In Program - Program Summary (PDF, 47 KB) PDF None English
DHCAA F-00855 Medication Therapy Management Case Management Software Requirements (PDF, 591 KB) PDF None English
DHCAA F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF, 47 KB) PDF None English
DHCAA F-00885 Specialized Medical Vehicle Insurance Documentation Checklist (PDF, 48 KB) PDF None English
DHCAA F-00885 Specialized Medical Vehicle Insurance Documentation Checklist Word None English
DHCF F-00898 Explanation of Medicare Benefits for Diabetic Supply Claims (PDF, 1341 KB) PDF None English
DHCF F-00898 Explanation of Medicare Benefits for Diabetic Supply Claims Word None English
DHCF F-00898A Explanation of Medicare Benefits for Diabetic Supply Claims Completion Instructions (PDF, 35 KB) PDF None English
DHCAA F-00914 BadgerCare Plus Tax Filer Information (PDF, 238 KB) PDF None English
DHCAA F-00914A BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) PDF None English
DHCAA F-00914S BadgerCare Plus Tax Filer Information - Spanish (PDF, 249 KB) PDF None Spanish
DHCAA F-00916 ADAP WCDP and WWWP Provider File Update Request (1444 KB) PDF None English
DHCAA F-00916 ADAP WCDP and WWWP Provider File Update Request Word None English
DHCAA F-00916A ADAP WCDP and WWWP Provider File Update Request Completion Instructions (28 KB) PDF None English
DHCAA F-00917 Provider Enrollment Application Process System None English
DHCF F-00922 Behavioral Health Integrated Care Health Home Certification Application (PDF, 380 KB) PDF None English
DHCF F-00922 Behavioral Health Integrated Care Health Home Certification Application Word None English
DHCAA F-00985 How the Affordable Care Act may affect SeniorCare members who get Prescriptions (PDF, 62 KB) PDF None English
  F-00985H How the Affordable Care Act may affect SeniorCare members who get Prescriptions (Hmong) (PDF, 72 KB) PDF None Hmong
  F-00985S How the Affordable Care Act may affect SeniorCare members who get Prescriptions (Spanish) (PDF, 71 KB) PDF None Spanish
HCF-01002 F-01002 HealthCheck Individual Health History (PDF, 797 KB) PDF None English
HCF-01002 F-01002 HealthCheck Individual Health History Word None English
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong (PDF, 861 KB) PDF None Hmong
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong Word None Hmong
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish (PDF, 434 KB) PDF None Spanish
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish Word None Spanish
HCF-01003 F-01003 Wisconsin Medicaid - Certification of Public Expenditures (PDF, 279 KB) PDF None English
HCF-01008 F-01008 Wisconsin Medicaid - Notification of Hospice Benefit Election (PDF, 91 KB) PDF None English
HCF-01008 F-01008 Wisconsin Medicaid - Notification of Hospice Benefit Election Word None English
HCF-01009 F-01009A Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under (PDF, 23 KB) PDF None English
HCF-01009 F-01009A Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under Word None English
HCF-01009H F-01009AH Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Hmong (PDF, 25 KB) PDF None Hmong
HCF-01009H F-01009AH Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Hmong Word None Hmong
HCF-01009S F-01009AS Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Spanish (PDF, 25 KB) PDF None Spanish
HCF-01009S F-01009AS Wisconsin Medicaid - Election of Hospice Benefit for members 20 and Under - Spanish Word None Spanish
HCF-01009B F-01009B Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older (PDF, 22 KB) PDF None English
HCF-01009B F-01009B Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older Word None English
HCF-01009BH F-01009BH Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Hmong (PDF, 24 KB) PDF None Hmong
HCF-01009BH F-01009BH Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Hmong Word None Hmong
HCF-01009BS F-01009BS Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Spanish (PDF, 25 KB) PDF None Spanish
HCF-01009BS F-01009BS Wisconsin Medicaid - Election of Hospice Benefit for members 21 and Older - Spanish Word None Spanish
HCF-01010 F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge (PDF, 87 KB) PDF None English
HCF-01010 F-01010 Wisconsin Medicaid - Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge Word None English
HCF-01011 F-01011 Wisconsin Medicaid - Physician Certification / Recertification of Terminal Illness (PDF, 92 KB) PDF None English
HCF-01011 F-01011 Wisconsin Medicaid - Physician Certification / Recertification of Terminal Illness Word None English
HCF-01012 F-01012 Reimbursement Request for a PASARR Level I Screen (PDF, 45 KB) PDF None English
HCF-01012 F-01012 Reimbursement Request for a PASARR Level I Screen Word None English
HCF-01012A F-01012A Reimbursement Request for a PASARR Level I Screen Instructions (PDF, 30 KB) PDF None English
HCF-01013 F-01013 Nurses Aide Training and Competency Test Reimbursement Request (PDF, 52 KB) PDF None English
HCF-01013 F-01013 Nurse Aide Training and Competency Test Reimbursement Request Word None English
HCF-01013A F-01013A Nurses Aide Training and Competency Test Reimbursement Request Instructions (PDF, 31 KB) PDF None English
HCF-01016 F-01016 Provider Suggestion (PDF, 12 KB) PDF None English
HCF-01017 F-01017 Wisconsin Medicaid - Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement (PDF, 37 KB) PDF None English
HCF-01017 F-01017 Wisconsin Medicaid - Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Word None English
HCF-01017A F-01017A Wisconsin Medicaid - Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Completion Instructions (PDF, 35 KB) PDF None English
HCF-01018 F-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers (PDF, 235 KB) PDF None English
HCF-01018 F-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers Word None English
HCF-01050 F-01050 Wisconsin Medicaid - Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification (PDF, 67 KB) PDF None English
HCF-01050A F-01050A Wisconsin Medicaid - Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions (PDF, 332 KB) PDF None English
HCF-01058 F-01058 Wisconsin Chronic Renal Disease Program - Drug Benefits Important Notice (PDF, 40 KB) PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review (PDF, 129 KB) PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review Word None English
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish (PDF, 131 KB) PDF None Spanish
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish Word None Spanish
HCF-01063 F-01063 HealthCheck Family History (PDF, 392 KB) PDF None English
HCF-01063 F-01063 HealthCheck Family History Word None English
HCF-01063S F-01063S HealthCheck Family History - Spanish (PDF, 391 KB) PDF None Spanish
HCF-01063S F-01063S HealthCheck Family History - Spanish Word None Spanish
HCF-01066 F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (PDF, 13 KB) PDF None English
HCF-01066 F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) Word None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF, 72 KB) PDF None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF, 13 KB) Word None English
HCF-01066AS F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age - Spanish (PDF, 62 KB) PDF None Spanish
HCF-01066AS F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age - Spanish Word None Spanish
HCF-01066B F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (PDF, 12 KB) PDF None English
HCF-01066B F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (PDF, 12 KB) Word None English
HCF-01066BS F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age) - Spanish (PDF, 77 KB) PDF None Spanish
HCF-01066BS F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age) - Spanish (PDF, 14 KB) Word None Spanish
HCF-01066S F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age) - Spanish (PDF, 40 KB) PDF None Spanish
HCF-01066S F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age) - Spanish Word None Spanish
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing (PDF, 280 KB) PDF None English
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing Word None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit (PDF, 195 KB) PDF None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit Word None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 to 8 Week Visit (PDF, 137 KB) PDF None English
HCF-01068B F-01068B HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 to 8 Week Visit Word None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit (PDF, 152 KB) PDF None English
HCF-01068C F-01068C HealthCheck Age Specific Documentation / General Pediatric Clinic - 4 Month Visit Word None English
HCF-01068D F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit (PDF, 193 KB) PDF None English
HCF-01068C F-01068D HealthCheck Age Specific Documentation / General Pediatric Clinic - 6 Month Visit Word None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit (PDF, 152 KB) PDF None English
HCF-01068E F-01068E HealthCheck Age Specific Documentation / General Pediatric Clinic - 9 Month Visit Word None English
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit (PDF, 169 KB) PDF None English
HCF-01068F F-01068F HealthCheck Age Specific Documentation / General Pediatric Clinic - 12 Month Visit Word None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit (PDF, 160 KB) PDF None English
HCF-01068G F-01068G HealthCheck Age Specific Documentation / General Pediatric Clinic - 15 Month Visit Word None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit (PDF, 172 KB) PDF None English
HCF-01068H F-01068H HealthCheck Age Specific Documentation / General Pediatric Clinic - 18 Month Visit Word None English
HCF-01068I F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit (PDF, 236 KB) PDF None English
HCF-01068I F-01068i HealthCheck Age Specific Documentation / General Pediatric Clinic - 24 Month Visit Word None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit (PDF, 160 KB) PDF None English
HCF-01068J F-01068J HealthCheck Age Specific Documentation / General Pediatric Clinic - Pre-school Visit Word None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit (PDF, 149KB) PDF None English
HCF-01068K F-01068K HealthCheck Age Specific Documentation / General Pediatric Clinic - Elementary School Visit Word None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit (PDF, 134 KB) PDF None English
HCF-01068L F-01068L HealthCheck Age Specific Documentation / General Pediatric Clinic - Teenager Visit Word None English
HCF-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey (PDF, 189 KB) PDF None English
HCF-01068M F-01068M HealthCheck Age Specific Documentation / Confidential Health Survey Word None English
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish (PDF, 134 KB) PDF None Spanish
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish Word None Spanish
HCF-01105 F-01105 Pre-Natal Care Coordination Pregnancy Questionnaire (PDF, 211 KB) PDF None English
HCF-01105A F-01105A Pre-Natal Care Coordination Pregnancy Questionnaire Completion Instructions (PDF, 67 KB) PDF None English
HCF-01105H F-01105H Pre-Natal Care Coordination Pregnancy Questionnaire - Hmong (PDF, 197 KB) PDF None Hmong
HCF-01105S F-01105S Pre-Natal Care Coordination Program Pregnancy Questionnaire - Spanish (PDF, 202 KB) PDF None Spanish
HCF-01112 F-01112 HealthCheck Verification Card Paper Form Center English
HCF-01118 F-01118 Child Care Coordination Family Questionnaire (PDF, 241 KB) PDF None English
HCF-01118A F-01118A Child Care Coordination Family Questionnaire Completion Instructions(PDF, 10 KB) PDF None English
HCF-01134 F-01134 Wisconsin Medicaid - Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit (PDF, 77 KB) PDF None English
HCF-01134 F-01134 Wisconsin Medicaid - Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit Word None English
HCF-01143 F-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification (PDF, 32 KB) PDF None English
HCF-01144 F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification (PDF, 30 KB) PDF None English
HCF-01145 F-01145 Wisconsin Hemophilia Home Care Program Residency Verification (PDF, 20 KB) PDF None English
HCF-01146 F-01146 Wisconsin Chronic Disease Program Provider Data Sheet (PDF, 45 KB) PDF None English
HCF-01149 F-01149 Wisconsin Medicaid - Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements (PDF, 45 KB) PDF None English
HCF-01149 F-01149 Wisconsin Medicaid - Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements Word None English
HCF-01153 F-01153 Breast Pump Order (PDF, 26 KB) PDF None English
HCF-01159 F-01159 Other Coverage Discrepancy Report (PDF, 73 KB) PDF None English
HCF-01159 F-01159 Other Coverage Discrepancy Report Word None English
HCF-01160 F-01160 Acknowledgement of Receipt of Hysterectomy Information (PDF, 131 KB) PDF None English
HCF-01160 F-01160 Acknowledgement of Receipt of Hysterectomy Information Word None English
DHCAA F-01160A Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-01160AH Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (Hmong) (PDF, 23 KB) PDF None English
DHCAA F-01160AS Acknowledgement of Receipt of Hysterectomy Information Completion Instructions (PDF, 23 KB) PDF None English
DHCAA F-01160H Acknowledgement of Receipt of Hysterectomy Information - Hmong (PDF, 57 KB) PDF None Hmong
DHCAA F-01160H Acknowledgement of Receipt of Hysterectomy Information - Hmong Word None Hmong
DHCAA F-01160S Acknowledgement of Receipt of Hysterectomy Information - Spanish (PDF, 42 KB) PDF None Spanish
DHCAA F-01160S Acknowledgement of Receipt of Hysterectomy Information - Spanish Word None Spanish
HCF-01161 F-01161 Abortion Certification Statements (PDF, 94 KB) PDF None English
HCF-01161 F-01161 Abortion Certification Statements Word None English
HCF-01162 F-01162 Certification of Emergency for Non-U.S. Citizens (PDF, 12 KB) PDF None English
HCF-01162A F-01162A Certification of Emergency for Non-U.S. Citizens (PDF, 21 KB) PDF None English
HCF-01164 F-01164 Consent for Sterilization (PDF, 123 KB) PDF None English
HCF-01164 F-01164 Consent for Sterilization Word None English
HCF-01164A F-01164A Consent for Sterilization Instructions (PDF, 119 KB) PDF None English
HCF-01164S F-01164S Consent for Sterilization - Spanish (PDF, 23 KB) PDF None Spanish
HCF-01164S F-01164S Consent for Sterilization - Spanish (PDF, 23 KB) Word None Spanish
HCF-01165 F-01165 Newborn Report (PDF, 50 KB) PDF None English
HCF-01165 F-01165 Newborn Report Word None English
HCF-01168 F-01168 Wisconsin Medicaid - Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases (PDF, 40 KB) PDF None English
HCF-01168 F-01168 Wisconsin Medicaid - Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases Word None English
HCF-01170 F-01170 Written Correspondence Inquiry (PDF, 57 KB) PDF None English
HCF-01170 F-01170 Written Correspondence Inquiry Word None English
HCF-01182 F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers (PDF, 48 KB) PDF None English
HCF-01182 F-01182 Wisconsin Medicaid - Declaration of Supervision for Nonbilling Providers Word None English
HCF-01184 F-01184 Wisconsin Hemophilia Home Care Program Application (PDF, 49 KB) PDF None English
HCF-01184A F-01184A Wisconsin Hemophilia Home Care Program Application Instructions (PDF, 38 KB) PDF None English
HCF-01185 F-01185 Wisconsin Adult Cystic Fibrosis Program Application (PDF, 84 KB) PDF None English
HCF-01185A F-01185A Wisconsin Adult Cystic Fibrosis Program Application Instructions (PDF, 39 KB) PDF None English
HCF-01186 F-01186 Wisconsin Chronic Renal Disease Program Application (PDF, 55 KB) PDF None English
HCF-01186A F-01186A Wisconsin Chronic Renal Disease Program Application Instructions (PDF, 39 KB) PDF None English
HCF-01187 F-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement (PDF, 46 KB) PDF None English
HCF-01187A F-01187A Wisconsin Hemophilia Home Care Program Financial Need Statement Instructions (PDF, 39 KB) PDF None English
HCF-01188 F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement (PDF, 46 KB) PDF None English
HCF-01188A F-01188A Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Instructions (PDF, 39 KB) PDF None English
HCF-01189 F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement (PDF, 50 KB) PDF None English
HCF-01189A F-01189A Wisconsin Chronic Renal Disease Program Financial Need Statement Instructions (PDF, 40 KB) PDF None English
HCF-01194 F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01195 F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01196 F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo (PDF, 41 KB) PDF None English
HCF-01197 F-01197 Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation (PDF, 23 KB) PDF None English
HCF-01197 F-01197 Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation Word None English
HCF-01197A F-01197A Wisconsin Medicaid - Certification of Need for Specialized Medical Vehicle Transportation Completion Instructions (PDF, 15 KB) PDF None English
HCF-01198 F-01198 Wisconsin Medicaid - Optional School-Based Services Activity Log Nursing / Therapy Medical Services (PDF, 122 KB) PDF None English
HCF-01198 F-01198 Wisconsin Medicaid - Optional School-Based Services Activity Log Nursing / Therapy Medical Services Word None English
HCF-01199 F-01199 Wisconsin Medicaid - Optional School-Based Services Activity Medication Administration (PDF, 113 KB) PDF None English
HCF-01199 F-01199 Wisconsin Medicaid - Optional School-Based Services Activity Medication Administration Word None English
DHCAA F-01234 Medical Benefits Explanation (PDF, 4048 KB) PDF None English
DHCAA F-01234 Medical Benefits Explanation Word None English
DHCAA F-01234A Medical Benefits Explanation Coimpletion Instructions (PDF, 128 KB) PDF None English
DHCF F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) (PDF, 620 KB) PDF None English
DHCF F-01247 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) Word None English
DHCF F-01247-1 Prior Authorization Drug Attachment for Sovaldi (Effective for use prior to December 1, 2014) (PDF, 589 KB) PDF None English
DHCF F-01247-1 Prior Authorization Drug Attachment for Sovaldi (Effective for use prior to December 1, 2014) Word None English
DHCF F-01247A Prior Authorization Drug Attachment for Hepatitis C Agents Completion Instructions (Effective for use on and after December 1, 2014) (PDF, 60 KB) PDF None English
DHCF F-01247A-1 Prior Authorization Drug Attachment for Sovaldi Completion Instructions (Effective for use prior to December 1, 2014) (PDF, 58 KB) PDF None English
DHCF F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) (PDF, 568 KB) PDF None English
DHCF F-01248 Prior Authorization Drug Attachment for Hepatitis C Agents (Effective for use on and after December 1, 2014) Word None English
DHCF F-01248-1 Prior Authorization Drug Attachment for Sovaldi Renewal (Effective for use prior to December 1, 2014) (PDF, 540 KB) PDF None English
DHCF F-01248-1 Prior Authorization Drug Attachment for Sovaldi Renewal (Effective for use prior to December 1, 2014) Word None English
DHCF F-01248A Prior Authorization Drug Attachment for Heaptitis C Agents Completion Instructions (Effective for use on and after December 1, 2014) (PDF, 40 KB) PDF None English
DHCF F-01248A-1 Prior Authorization Drug Attachment for Sovaldi Renewal Completion Instructions (Effective for use prior to December 1, 2014) (PDF, 23 KB) PDF None English
DHCF F-01249 Prior Authorization Drug Attachment for Stribild (PDF, 541 KB) PDF None English
DHCF F-01249 Prior Authorization Drug Attachment for Stribild Word None English
DHCF F-01249A Prior Authorization Drug Attachment for Stribild Completion Instructions (PDF, 23 KB) PDF None English
DHCF F-01252 FoodShare Employment and Training - Initial Appointment Letter Word None English
DHCF F-01253 FoodShare Employment and Training - Final Notice Appointment Letter Word None English
DHCF F-01254 FoodShare Employment and Training - Employment Plan (EP) Appointment Letter Word None English
DHCF F-01255 FoodShare Employment and Training - Job Club Appointment Letter Word None English
DHCF F-01256 FoodShare Employment and Training - Discuss Participant Appointment Letter Word None English
DHCF F-01257 FoodShare Employment and Training - Workshop Appointment Letter Word None English
DHCAA F-01270 Comprehensive Community Services Non-Traditional Approval PDF None English
DHCAA F-01270 Comprehensive Community Services Non-Traditional Approval Word None English
HCF-01302 F-01302 Weekly Driver's Vehicle Inspection Report (PDF, 113 KB) PDF None English
HCF-01302 F-01302 Weekly Driver's Vehicle Inspection Report Word None English
HCF-01302A F-01302A Weekly Driver's Vehicle Inspection Report Instructions (PDF, 25 KB) PDF None English
  F-01359 Historical Earnings Verification Request Word None English
  F-01361 ForwardHealth Provider Express Enrollment Change of Address System None English
HCF-10075 F-10075 Wisconsin Well Woman Medicaid Determination (PDF, 78 KB) Paper Form Center English
HCF-10076 F-10076 SeniorCare Application (PDF, 179 KB) Paper Form Center English
HCF-10076A F-10076A SeniorCare Instructions for Application Form (PDF, 71 KB) Paper Form Center English
HCF-10076AH F-10076AH SeniorCare Instructions for Application Form - Hmong (PDF, 128 KB) PDF None Hmong
HCF-10076AS F-10076AS SeniorCare Instructions for Application Form - Spanish (PDF, 124 KB) PDF None Spanish
HCF-10080 F-10080 SeniorCare Authorization of Representative (PDF, 486 KB) PDF None English
HCF-10081 F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application Paper Form Center English
DHCAA F-10081A BadgerCare Plus Express Enrollment for Pregnant Women Application Instructions (PDF, 100 KB) PDF None English
HCF-10093 F-10093 Medicaid and BadgerCare Plus Overpayment Notice (PDF, 79 KB) PDF None English
HCF-10093 F-10093 Medicaid and BadgerCare Plus Overpayment Notice Word None English
HCF-10093S F-10093S Medicaid and BadgerCare Overpayment Notice - Spanish (PDF, 59 KB) PDF None Spanish
HCF-10093 F-10093S Medicaid and BadgerCare Plus Overpayment Notice - Spanish Word None English
HCF-10095 F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (PDF, 395 KB) PDF None English
HCF-10095S F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish (PDF, 35 KB) PDF None Spanish
HCF-10096 F-10096 Community Spouse Asset Share Notice (PDF, 658 KB) PDF None English
HCF-10096S F-10096S Community Spouse Asset Share Notice - Spanish (PDF, 39 KB) PDF None Spanish
HCF-10097 F-10097 Medicaid Income Allocation Notice (PDF, 44 KB) PDF None English
HCF-10097S F-10097S Medicaid Income Allocation Notice - Spanish (PDF, 49 KB) PDF None Spanish
HCF-10098 F-10098 Medicaid Member Asset Allocation Notice (PDF, 85 KB) PDF None English
HCF-10098S F-10098S Medicaid Member Asset Allocation Notice - Spanish (PDF, 39 KB) PDF None Spanish
HCF-10099 F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB) PDF None English
HCF-10101 F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet (PDF, 532 KB) Paper Form Center English
HCF-10101H F-10101H Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 709 KB) PDF None Hmong
HCF-10101S F-10101S Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Spanish(PDF,704 KB) PDF None Spanish
HCF-10106 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 None English
HCF-10106S 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 None Spanish
HCF-10107 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 None English
HCF-10107S 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 None Spanish
HCF-10108 F-10108 Medicaid Manual Notice for Cost of Care Contribution (PDF, 168 KB) PDF None English
HCF-10108A F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions (PDF, 509 KB) PDF None English
HCF-10109 F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) PDF None English
HCF-10110 F-10110 Medicaid / BadgerCare Plus Certification System None English
HCF-10110 F-10110A Medicaid / BadgerCare Plus Certification Instructions System None English
HCF-10111 F-10111 Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) PDF None English
HCF-10111A F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 31 KB) PDF None English
HCF-10112 F-10112 Medicaid Disability Application (PDF, 1982 KB) Paper Form Center English
HCF-10112S F-10112S Medicaid Disability Application - Spanish (PDF, 275 KB) PDF None Spanish
HCF-10114 F-10114 Medicaid Disability Redetermination Report (PDF, 222 KB) PDF None English
HCF-10115 F-10115 BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) PDF None English
HCF-10115S F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish (PDF, 94 KB) PDF None Spanish
HCF-10119 F-10119 Temporary Enrollment For Family Planning Only Services Paper Form Center English
HCF-10119A F-10119A Temporary Enrollment For Family Planning Only Services Instructions (PDF, 279 KB) PDF None English
HCF-10121 F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration (PDF, 29 KB) PDF None English
HCF-10122 F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information (PDF, 117 KB) PDF None English
HCF-10126 F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) PDF None English
HCF-10126H F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 125 KB) PDF None Hmong
HCF-10126S F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 47 KB) PDF None Spanish
HCF-10127 F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption (PDF, 108 KB) PDF None English
HCF-10129 F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application (PDF, 45 KB) PDF None English
HCF-10129H F-10129H Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 46 KB) PDF None Hmong
HCF-10129S F-10129S Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 29 KB) PDF None Spanish
HCF-10130 F-10130 Medicaid Presumptive Disability (PDF, 51 KB) PDF None English
HCF-10137 F-10137 Medicaid Change Report (PDF, 88 KB) Paper Form Center English
HCF-10137H F-10137H Medicaid Change Report - Hmong (PDF, 98 KB) PDF None Hmong
HCF-10137S F-10137S Medicaid Change Report - Spanish (PDF, 65 KB) PDF None Spanish
HCF-10138 F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) PDF None English
HCF-10139 F-10139 BadgerCare Plus Premium Information / Payment (PDF, 76 KB) PDF None English
HCF-10139S F-10139S BadgerCare Plus Premium Information / Payment - Spanish (PDF, 37 KB) PDF None Spanish
HCF-10140 F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (PDF, 148 KB) PDF None English
HCF-10140S F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 152 KB) PDF None Spanish
HCF-10141 F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) PDF None English
HCF-10142 F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant (PDF, 107 KB) PDF None English
HCF-10143 F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice (PDF, 46 KB) PDF None English
HCF-10144 F-10144 Life Insurance Inquiry Word None English
HCF-10145 F-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding (PDF, 25 KB) PDF None English
HCF-10146 F-10146 Employment Verification of Earnings Word None English
HCF-10147 F-10147 Wisconsin Veterans Home at King - Medicaid Review (PDF, 253 KB) PDF None English
HCF-10150 F-10150 Your Rights and Responsibilities for Health Care / FoodShare (PDF, 81 KB) PDF None English
DHCAA F-10150A Your Rights and Responsibilities for Health Care (PDF, 56 KB) PDF None English
DHCAA F-10150AS Your Rights and Responsibilities for Health Care - Spanish (PDF, 56 KB) PDF None English
DHCAA F-10150B Your Rights and Responsibilities for FoodShare (PDF, 81 KB) PDF None English
DHCAA F-10150BS Your Rights and Responsibilities for FoodShare - Spanish (PDF, 60 KB) PDF None English
HCF-10150S F-10150S Your Rights and Responsibilities for Health Care / FoodShare (PDF, 71 KB) PDF None Spanish
HCF-10151 F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) PDF None English
HCF-10154 F-10154 Statement of Identity for Children Under 18 Years of Age (PDF, 33 KB) PDF None English
HCF-10154H F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong (PDF, 33 KB) PDF None Hmong
HCF-10154R F-10154R Statement of Identity for Children Under 18 Years of Age - Russian (PDF, 107 KB) PDF None Russian
HCF-10154S F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish (PDF, 27 KB) PDF None Spanish
HCF-10161 F-10161 Statement of Citizenship and / or Identity for Special Populations (PDF, 116 KB) PDF None English
HCF-10162 F-10162 Verification of Veterans Benefits (PDF, 53 KB) PDF None English
HCF-10171 F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) PDF None English
HCF-10175 F-10175 Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) PDF None English
HCF-10180 F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) PDF None English
HCF-10182 F-10182 BadgerCare Plus Application Packet (PDF, 2417 KB) Paper Form Center English
HCF-10182H F-10182H BadgerCare Plus Application Packet - Hmong (PDF, 1310 KB) PDF None Hmong
HCF-10182S F-10182S BadgerCare Plus Application Packet - Spanish (PDF, 1460 KB) PDF None Spanish
HCF-10183 F-10183 BadgerCare Plus Change Report (PDF, 345 KB) Paper Form Center English
HCF-10183H F-10183H BadgerCare Plus Change Report - Hmong (PDF, 284 KB) PDF None Hmong
HCF-10183S F-10183S BadgerCare Plus Change Report - Spanish (PDF, 340 KB) PDF None Spanish
HCF-10184 F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) Word None English
HCF-10185 F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication Word None English
HCF-10187 F-10187 Medicaid Divestment Penalty and Undue Hardship Notice Word None English
HCF-10188 F-10188 Medicaid Undue Hardship Waiver Decision Word None English
HCF-10189 F-10189 Medicaid Undue Hardship Bedhold Notice Word None English
HCF-10190 F-10190 Medicaid Issuer of Annuity - Notice of Obligation (PDF, 641 KB) PDF None English
HCF-10191 F-10191 Medicaid Annuity Beneficiary Designation (PDF, 1.4 MB) PDF None English
HCF-10192 F-10192 Medicaid Annuity Information - Disclosure (PDF, 2.1 MB) PDF None English
HCF-10193 F-10193 Medicaid Undue Hardship Request (PDF, 2.7 MB) PDF None English
HCF-11018 F-11018 Prior Authorization Request Form (PA/RF) (PDF, 148 KB) PDF None English
HCF-11020 F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) (PDF, 122 KB) PDF None English
HCF-11020 F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Word None English
HCF-11020A F-11020A Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Completion Instructions (PDF, 54 KB) PDF None English
HCF-11049 F-11049 Prior Authorization / Drug Attachment (PA/DGA) (PDF, 1337 KB) PDF None English
HCF-11049 F-11049 Prior Authorization / Drug Attachment (PA/DGA) Word None English
HCF-11049A F-11049A Prior Authorization / Drug Attachment (PA/DGA) Completion Instructions (PDF, 52 KB) PDF None English
HCF-11075 F-11075 Prior Authorization / Preferred Drug List (PA PDL) Exemption Request (PDF, 1860 KB) PDF None English
HCF-11075 F-11075 Prior Authorization / Preferred Drug List (PA PDL) Exemption Request Word None English
HCF-11075A F-11075A Prior Authorization / Preferred Drug List (PA PDL) Exemption Request Completion Instructions (PDF, 67 KB) PDF None English
HCF-11077 F-11077 Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors (PDF, 50 KB) PDF None English
HCF-11077 F-11077 Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors Word None English
HCF-11077A F-11077A Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors Completion Instructions (PDF, 43 KB) PDF None English
HCF-11078 F-11078 BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs (PDF, 43 KB) PDF None English
HCF-11078 F-11078 BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Word None English
HCF-11078A F-11078A BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions (PDF, 55 KB) PDF None English
HCF-11083 F-11083 Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) (PDF, 65 KB) PDF None English
HCF-11083 F-11083 Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) Word None English
HCF-11083A F-11083A Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) Completion Instructions (PDF, 46 KB) PDF None English
HCF-11097 F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents (PDF, 60 KB) PDF None English
HCF-11097 F-11097 Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents Word None English
HCF-11097A F-11097A Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents Completion Instructions (PDF, 60 KB) PDF None English
HCF-11183 F-11183 Pharmacy Services Lock-In Program Member (PDF, 25 KB) Referral to Another Provider for Services PDF None English
HCF-11183 F-11183 Pharmacy Services Lock-In Program Member Referral to Another Provider for Services Word None English
HCF-11304 F-11304 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis (PDF, 61 KB) PDF None English
HCF-11304 F-11304 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Word None English
HCF-11304A F-11304A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Completion Instructions (PDF, 55 KB) PDF None English
HCF-11305 F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease (PDF, 54 KB) PDF None English
HCF-11305 F-11305 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease Word None English
HCF-11305A F-11305A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease Completion Instructions (PDF, 52 KB) PDF None English
HCF-11306 F-11306 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis (PDF, 1431 KB) PDF None English
HCF-11306 F-11306 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis Word None English
HCF-11306A F-11306A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis Completion Instructions (PDF, 60 KB) PDF None English
HCF-11307 F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis (PDF, 535 KB) PDF None English
HCF-11307 F-11307 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis Word None English
HCF-11307A F-11307A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis Completion Instructions (PDF, 53 KB) PDF None English
HCF-11308 F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis (PDF, 539 KB) PDF None English
HCF-11308 F-11308 Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis Word None English
HCF-11308A F-11308A Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis Completion Instructions (PDF, 54 KB) PDF None English
HCF-12022 F-12022 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Provider Appeal (PDF, 18 KB) PDF None English
HCF-12022 F-12022 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Provider Appeal Word None English
HCF-12023 F-12023 Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption Paper Program English
HCF-12023S F-12023S Wisconsin Medicaid and BadgerCare MC Birth to Three Program Exemption - Spanish Paper Program Spanish
HCF-12024 F-12024 Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model Paper Program English
HCF-12024A F-12024A Wisconsin Medicaid SSI HMO Program HMO Enrollment Choice - Milwaukee Model Completion Instructions Paper Program English
HCF-12025 F-12025 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request Paper Program English
HCF-12025A F-12025A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Mental Health, Severe Developmental Disability in Children up to Age 3, or Methadone Treatment Exemption Request Completion Instructions Paper Program English
HCF-12026 F-12026 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request Paper Program English
HCF-12026A F-12026A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Continuity of Care Exemption Request Completion Instructions Paper Program English
HCF-12027 F-12027 Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request Paper Program English
HCF-12027A F-12027A Wisconsin Medicaid and BadgerCare Plus Managed Care Program High Risk Pregnancy Exemption Request Completion Instructions Paper Program English
HCF-12028 F-12028 Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request Paper Program English
HCF-12028A F-12028A Wisconsin Medicaid and BadgerCare Plus Managed Care Program AIDS or HIV Positive Exemption Request Completion Instructions Paper Program English
HCF-12029 F-12029 Managed Care Disenrollment Request Paper Program English
HCF-12085 F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice Paper Program English
HCF-12089 F-12089 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request Paper Program English
HCF-12089A F-12089A Wisconsin Medicaid and BadgerCare Plus Managed Care Program Child / Adolescent Day Treatment Services or In-Home Mental Health and Substance Abuse Treatment Services Exemption Request Information and Instructions Paper Program English
HCF-13023 F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer Information and Instructions (PDF, 1.3 MB) PDF None English
HCF-13024 F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions (PDF, 1.4 MB) PDF None English
HCF-13025 F-13025 BadgerCare Plus Premium Employer Wage Withholding (PDF, 92 KB) PDF None English
HCF-13026 F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer (PDF, 202 KB) PDF None English
HCF-13033 F-13033 Probate Claims Notice (PDF, 53 KB) PDF None English
HCF-13038 F-13038 Notice of Intent to File a Lien Paper Form Center English
HCF-13039 F-13039 Estate Recovery Program (ERP) Disclosure (PDF, 30 KB) PDF None English
HCF-13039A F-13039A Estate Recovery Program (ERP) Disclosure Instructions (PDF, 20 KB) PDF None English
HCF-13046 F-13046 Adjustment / Reconsideration Request (PDF, 104 KB) PDF None English
HCF-13046 F-13046 Adjustment / Reconsideration Request Word None English
HCF-13046A F-13046A Adjustment / Reconsideration Request Completion Instructions (PDF, 49 KB) PDF None English
HCF-13047 F-13047 Timely Filing Appeals Request (PDF, 55 KB) PDF None English
HCF-13047 F-13047 Timely Filing Appeals Request Word None English
HCF-13066 F-13066 Claim Refund (PDF, 69 KB) PDF None English
HCF-13066 F-13066 Claim Refund Word None English
HCF-13066A F-13066A Claim Refund Completion Instructions (PDF, 32 KB) PDF None English
HCF-13072 F-13072 Noncompound Drug Claim (PDF, 547 KB) PDF None English
HCF-13072 F-13072 Noncompound Drug Claim Word None English
HCF-13072A F-13072A Noncompound Drug Claim Completion Instructions (PDF, 50 KB) PDF None English
HCF-13073 F-13073 Compound Drug Claim (PDF, 60 KB) PDF None English
HCF-13073 F-13073 Compound Drug Claim Word None English
HCF-13073A F-13073A Compound Drug Claim Completion Instructions (PDF, 27 KB) PDF None English
HCF-13074 F-13074 Pharmacy Special Handling Request (PDF, 506 KB) PDF None English
HCF-13074 F-13074 Pharmacy Special Handling Request Word None English
HCF-13074A F-13074A Pharmacy Special Handling Request Completion Instructions (PDF, 32 KB) PDF None English
HCF-13145 F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure (PDF, 171 KB) PDF None English
HCF-13146 F-13146 Wisconsin Medicaid HIPAA Privacy Revocation of Authorization (PDF, 172 KB) PDF None English
HCF-13147 F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request (PDF, 158 KB) PDF None English
HCF-13148 F-13148 Wisconsin Medicaid HIPAA Privacy Access Request (PDF, 178 KB) PDF None English
HCF-13149 F-13149 Wisconsin Medicaid HIPAA Privacy Accounting Request (PDF, 152 KB) PDF None English
HCF-13150 F-13150 Wisconsin Medicaid HIPAA Privacy Alternate Communication Request (PDF, 168 KB) PDF None English
HCF-13151 F-13151 Wisconsin Medicaid HIPAA Privacy Amendment Request (PDF, 151 KB) PDF None English
HCF-13152 F-13152 Wisconsin Medicaid HIPAA Privacy Complaint (PDF, 158 KB) PDF None English
HCF-13153 F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure (PDF, 168 KB) PDF None English
HCF-13154 F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request (PDF, 172 KB) PDF None English
HCF-13155 F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request (PDF, 148 KB) PDF None English
HCF-13156 F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request (PDF, 163 KB) PDF None English
HCF-13157 F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request (PDF, 149 KB) PDF None English
HCF-13158 F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint (PDF, 168 KB) PDF None English
HCF-13159 F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request (PDF, 151 KB) PDF None English
HCF-13160 F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization (PDF, 163 KB) PDF None English
HCF-13161 F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure (PDF, 178 KB) PDF None English
HCF-13162 F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request (PDF, 183 KB) PDF None English
HCF-13163 F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request (PDF, 152 KB) PDF None English
HCF-13164 F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request (PDF, 163 KB) PDF None English
HCF-13165 F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request (PDF, 154 KB) PDF None English
HCF-13166 F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint (PDF, 157 KB) PDF None English
HCF-13167 F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization (PDF, 171 KB) PDF None English
HCF-13168 F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request (PDF, 155 KB) PDF None English
HCF-13174 F-13174 Estate Recovery Program (ERP) Heir Information (PDF, 101 KB) PDF None English
HCF-13175 F-13175 Medicaid / Family Care / Partnership / BadgerCare Plus / (PDF, 24 KB) Estate Recovery Notification of Death (PDF, 24 KB) PDF None English
HCF-13393 F-13393 Trading Partner 835 Designation (PDF, 58 KB) PDF None English
HCF-13993 F-13393 Trading Partner 835 Designation Word None English
HCF-13393A F-13393A Trading Partner 835 Designation Completion Instructions (PDF, 31 KB) PDF None English
HCF-13470 F-13470 Claim Form Attachment Cover Page (PDF, 100 KB) PDF None English
HCF-13470 F-13470 Claim Form Attachment Cover Page Word None English
HCF-13470A F-13470A Claim Forms Attachment Cover Page Completion Instructions (PDF, 18 KB) PDF None English
HCF-14014 F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF, 199 KB) PDF None English
HCF-14014AS F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 292 KB) PDF None Spanish
HCF-16001 F-16001 Negative Notice (PDF, 154 KB) PDF None English
HCF-16001 F-16001 Negative Notice Word None English
HCF-16001S F-16001S Negative Notice - Spanish (PDF, 74 KB) PDF None Spanish
HCF-16001S F-16001S Negative Notice - Spanish Word None Spanish
HCF-16004 F-16004 Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits (PDF, 32 KB) PDF None English
HCF-16004H F-16004H Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Hmong (PDF, 31 KB) PDF None Hmong
HCF-16004S F-16004S Designation of Authorized Buyer / Alternate Payee for FoodShare Benefits - Spanish (PDF, 33 KB) PDF None Spanish
HCF-16006 F-16006 FoodShare Wisconsin Change Report (PDF, 250 KB) Paper Form Center English
  F-16006AR FoodShare Wisconsin Change Report - Arabic (PDF, 137 KB) PDF None Arabic
HCF-16006H F-16006H FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) PDF None Hmong
  F-16006R FoodShare Wisconsin Change Report - Russian (PDF, 305 KB) PDF None Russian
HCF-16006S F-16006S FoodShare Wisconsin Change Report - Spanish (PDF, 133 KB) PDF None Spanish
HCF-16011 F-16011 Quality Assurance (QA) Sample Check List (PDF, 226 KB) PDF None English
HCF-16014 F-16014 Notice of Program Violation (PDF, 43 KB) PDF None English
HCF-16015 F-16015 Positive Notice (PDF, 134 KB) PDF None English
HCF-16015 F-16015 Positive Notice Word None English
HCF-16015S F-16015S Positive Notice - Spanish (PDF, 46 KB) PDF None Spanish
HCF-16015S F-16015S Positive Notice - Spanish Word None Spanish
HCF-16019A F-16019A FoodShare Wisconsin Registration / Important Information (PDF, 170 KB) Paper Form Center English
  F-16019AAR FoodShare Wisconsin Registration / Important Information - Arabic (PDF, 276 KB) PDF None Arabic
HCF-16019AH F-16019AH FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 238 KB) PDF None Hmong
  F-16019AR FoodShare Wisconsin Registration / Important Information - Russian (PDF, 287 KB) PDF None Russian
HCF-16019AS F-16019AS FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 299 KB) PDF None Spanish
HCF-16019B F-16019B FoodShare Wisconsin Application / Registration (PDF, 657 KB) Paper Form Center English
HCF-16019BH F-16019BH FoodShare Wisconsin Application / Registration - Hmong (PDF, 712 KB) PDF None Hmong
HCF-16019BS F-16019BS FoodShare Wisconsin Application / Registration - Spanish (PDF, 677 KB) PDF None Spanish
HCF-16021 F-16021 Student Financial Report (PDF, 194 KB) PDF None English
HCF-16022 F-16022 Social Security Number Referral (PDF, 61 KB) PDF None English
HCF-16022H F-16022H Social Security Number Referral - Hmong (PDF, 28 KB) PDF None Hmong
HCF-16022S F-16022S Social Security Number Referral - Spanish (PDF, 26 KB) PDF None Spanish
HCF-16023 F-16023 Striker Evaluation (PDF, 395 KB) PDF None English
HCF-16024 F-16024 Notice of Disqualification (PDF, 110 KB) PDF None English
HCF-16024S F-16024S Notice of Disqualification - Spanish (PDF, 73 KB) PDF None Spanish
HCF-16025 F-16025 Disqualification Consent Agreement (PDF, 71 KB) PDF None English
HCF-16025S F-16025S Disqualification Consent Agreement - Spanish (PDF, 72 KB) PDF None Spanish
HCF-16026 F-16026 Prosecution Diversion Agreement (PDF, 251 KB) PDF None English
HCF-16028 F-16028 Notice of FoodShare Over issuance (PDF, 288 KB) PDF None English
HCF-16028S F-16028S Notice of FoodShare Overissuance - Spanish (PDF, 170 KB) PDF None Spanish
HCF-16029 F-16029 FoodShare Wisconsin Repayment Agreement (PDF, 108 KB) PDF None English
HCF-16029S F-16029S FoodShare Wisconsin Repayment Agreement - Spanish (PDF, 113 KB) PDF None Spanish
HCF-16030 F-16030 FoodShare Wisconsin Under / Over Issuance Worksheet (PDF, 35 KB) PDF None English
HCF-16031 F-16031 Student Aid and Expense Worksheet (PDF, 256 KB) PDF None English
HCF-16033 F-16033 FoodShare Worksheet (PDF, 45 KB) PDF None English
HCF-16034 F-16034 Self-Employment Income Worksheet - Corporation (PDF, 25 KB) PDF None English
HCF-16035 F-16035 Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 28 KB) PDF None English
HCF-16036 F-16036 Self-Employment Income Worksheet - Partnership (PDF, 27 KB) PDF None English
HCF-16037 F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 34 KB) PDF None English
HCF-16037 F-16037A Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business for Magi Based Assistance Groups (PDF, 43 KB) PDF None English
HCF-16038 F-16038 Administrative Disqualification Hearing Notice (PDF, 101 KB) PDF None English
HCF-16039 F-16039 Waiver of Administrative Disqualification Hearing (PDF, 141 KB) PDF None English
HCF-16039S F-16039S Waiver of Administrative Disqualification Hearing - Spanish (PDF, 143 KB) PDF None Spanish
HCF-16050 F-16050 Agency Response to the State Quality Assurance (QA) FoodShare (FS) Finding (PDF, 183 KB) PDF None English
HCF-16060 F-16060 Disaster FoodShare Wisconsin Assistance Application (PDF, 118 KB) PDF None English
HCF-16060S F-16060S Disaster FoodShare Wisconsin Assistance Application - Spanish (PDF, 75 KB) PDF None Spanish
HCF-16066 F-16066 FoodShare Wisconsin Income Change Report (PDF, 80 KB) Paper Form Center English
  F-16066AR FoodShare Wisconsin Income Change Report - Arabic (PDF, 180 KB) PDF None Arabic
HCF-16066H F-16066H FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) PDF None Hmong
  F-16066R FoodShare Wisconsin Income Change Report - Russian (PDF, 211 KB) PDF None Russian
HCF-16066S F-16066S FoodShare Wisconsin Income Change Report - Spanish (PDF, 87 KB) PDF None Spanish
HCF-16073 F-16073 FoodShare Wisconsin Nonfinancial Worksheet (PDF, 214 KB) PDF None English
HCF-16076 F-16076 FoodShare and/or Child Care Six Month Report Word None English
HCF-16076A F-16076A FoodShare and/or Child Care Six Month Report Form Instructions Word None English
HCF-16076AH F-16076AH FoodShare and/or Child Care Six Month Report Form Instructions - Hmong Word None Hmong
HCF-16076AS F-16076AS FoodShare and/or Child Care Six Month Report Instructions - Spanish Word None Spanish
HCF-16076H F-16076H FoodShare and/or Child Care Six Month Report (Hmong) Word None Hmong
HCF-16076S F-16076S FoodShare and/or Child Care Six Month Report - Spanish Word None Spanish
HCF-16083 F-16083 Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) PDF None English
HCF-16104 F-16104 Local Agency Customer Feedback (PDF, 129 KB) Paper Form Center English
HCF-16104 F-16104H Local Agency Customer Feedback (Hmong) (PDF, 55 KB) PDF None English
HCF-16104S F-16104S Local Agency Customer Feedback - Spanish (PDF, 29 KB) Paper Form Center Spanish
HCF-9002 F-19002 Affidavit of Return or Exchange of Food Coupons (PDF, 615 KB) PDF None English
DDE-0812 F-20812 SSI-E Natural Residential Setting Application Checklist (PDF, 73 KB) PDF None English
DDE-0812 F-20812 SSI-E Natural Residential Setting Application Checklist Word None English
DDE-0817 F-20817 Assessment Worksheet for Natural Residential Setting (PDF, 28 KB) PDF None English
DDE-0817 F-20817 Assessment Worksheet for Natural Residential Setting Word None English
DDE-0817A F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses (PDF, 16 KB) PDF None English
DDE-0817A F-20817A Assessment Worksheet for Natural Residential Setting - for Individuals with Serious and Persistent Mental Illness and/or Alcohol and Other Drug Dependent Diagnoses Word None English
DDE-0817S F-20817S Assessment Worksheet for Natural Residential Setting - Spanish (PDF, 23 KB) PDF None Spanish
DDE-0818 F-20818 Certification for SSI-E Exceptional Expense Supplement (PDF, 75 KB) PDF None English
DDE-0818 F-20818 Certification for SSI-E Exceptional Expense Supplement Word None English
DDE-0818S F-20818S Certification for SSI-E Exceptional Expense Supplement - Spanish (PDF, 71 KB) PDF None Spanish
DDE-2539 F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate (PDF, 96 KB) PDF None English
DDE-2564 F-22564 Authorization for Retroactive Caretaker Supplement (CTS)* (PDF, 28 KB) PDF None English
DDE-2565 F-22565 Authorization for Recoupment Caretaker Supplement (CTS)* (PDF, 14 KB) PDF None English
DDE-2565 F-22565 Authorization for Recoupment Caretaker Supplement Word None English
DDE-22571 F-22571 Caretaker Supplement Application (PDF, 218 KB) PDF None English
DDE-22571A F-22571A Caretaker Supplement (CTS) Instructions for Application (PDF, 47 KB) PDF None English
DDE-2571AS F-22571AS Caretaker Supplement (CTS) Instructions for Application - Spanish (PDF, 54 KB) PDF None Spanish
DDE-2599 F-22599 Appointment of Authorized Representative for Supplemental Security Income (SSI) (PDF, 21 KB) PDF None English
  F-82009TC Confidential Information Release Authorization for Transportation Complaint Research Word None English