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Forms: Numeric List - HCAA
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 / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
DHCAA F-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request PDF None English
DHCAA F-00020 ForwardHealth Drug Addition Review Request PDF None English
DHCAA F-00021 ForwardHealth HealthCheck Referral PDF None English
DHCAA F-00023 ForwardHealth Case Management Agency Self-Audit Checklist PDF None English
DHCAA F-00030 ForwardHealth State Maximum Allowed Cost Drug Pricing Review Request PDF None English
DHCAA F-00030 ForwardHealth State Maximum Allowed Cost Drug Pricing Review Request Word None English
DHCAA F-00030A ForwardHealth State Maximum Allowed Cost Drug Pricing Review Request Completion Instructions PDF None English
DHCAA F-00065 ForwardHealth Roster Billing Form for Reimbursement for Treatment and Vaccination of the Uninsured Excel None English
DHCAA F-00065A ForwardHealth Roster Billing Form Completion Instructions Reimbursement for Treatment and Vaccination of the Uninsured PDF None English
DCHAA F-00079 ForwardHealth Prior Authorization Drug Attachment for Provigil and Nuvigil PDF None English
DCHAA F-00079 ForwardHealth Prior Authorization Drug Attachment for Provigil and Nuvigil Word None English
DCHAA F-00079A ForwardHealth Prior Authorization Drug Attachment for Provigil and Nuvigil Completion Instructions PDF None English
DCHAA F-00080 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Symlin PDF None English
DCHAA F-00080 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Word None English
DCHAA F-00080A ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Symlin Completion Instructions PDF None English
DCHAA F-00081 ForwardHealth Prior Authorization Drug Attachment for Suboxone and Buprenorphine PDF None English
DCHAA F-00081 ForwardHealth Prior Authorization Drug Attachment for Suboxone and Buprenorphine Word None English
DCHAA F-00081A ForwardHealth Prior Authorization Drug Attachment for Suboxone and Buprenorphine Completion Instructions PDF None English
DHCAA F-00098 Summary of Information Letter Word None English
DHCAA F-00100 State Vital Records Cover Letter Word None English
DHCAA F-00100E Enrollment Services Center State Vital Records Letter Word None English
DHCAA F-00101 Authorization to Request Birth Records Word None English
DHCAA F-00107 Self-Employment Income Report PDF None English
DHCAA F-00107H Self-Employment Income Report - Hmong PDF None Hmong
DHCAA F-00107S Self-Employment Income Report - Spanish PDF None Spanish
DHCAA F-00107W Self-Employment Income Report (Worksheet) PDF None English
DHCAA F-00136 FoodShare Employment and Training (FSET) Participation Agreement PDF None English
DHCAA F-00136H FoodShare Employment and Training (FSET) Participation Agreement - Hmong PDF None Hmong
DHCAA F-00136S FoodShare Employment and Training (FSET) Participation Agreement - Spanish PDF None Spanish
DHCAA F-00142 ForwardHealth Prior Authorization Drug Attachment for Synagis PDF None English
DHCAA F-00142 ForwardHealth Prior Authorization Drug Attachment for Synagis Word None English
DHCAA F-00142A ForwardHealth Prior Authorization Drug Attachment for Synagis Completion Instructions PDF None English
DHCAA F-00154 Wisconsin Consultative Examination Inquiry PDF None English
DHCAA F-00162 ForwardHealth Prior Authorization Drug Attachment for Lovaza PDF None English
DHCAA F-00162 ForwardHealth Prior Authorization Drug Attachment for Lovaza Word None English
DHCAA F-00162I ForwardHealth Prior Authorization Drug Attachment for Lovaza Completion Instructions PDF None English
DHCAA F-00163 ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs PDF None English
DHCAA F-00163 ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Word None English
DHCAA F-00163A ForwardHealth Prior Authorization Drug Attachment for Anti-Obesity Drugs Completion Instructions PDF None English
DCHAA F-00194 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids PDF None English
DHCAA F-00194 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids Word None English
DCHAA F-00194A ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids Completion Instructions PDF None English
DHCAA F-00204 ForwardHealth Prior Authorization Drug Attachment for Singulair PDF None English
DHCAA F-00204 ForwardHealth Prior Authorization Drug Attachment for Singulair Word None English
DHCAA F-00204A ForwardHealth Prior Authorization Drug Attachment for Singulair Completion Instructions PDF None English
DHCAA F-00212 ForwardHealth Prior Authorization Intensive In-Home Mental Health / Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment PDF None English
DHCAA F-00212 ForwardHealth Prior Authorization Intensive In-Home Mental Health / Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment Word None English
DHCAA F-00212A ForwardHealth Prior Authorization Intensive In-Home Mental Health / Substance Abuse Services Assessment and Recovery / Treatment Plan Attachment Completion Insttructions PDF None English
DHCAA F-00219 Self-Employment Income Report - Farmer PDF None English
DHCAA F-00219H Self-Employment Income Report - Farmer - Hmong PDF None Hmong
DHCAA F-00219S Self-Employment Income Report - Farmer - Spanish PDF None Spanish
DHCAA F-00219W Self-Employment Income Report - Farmer (Worksheet) 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 ForwardHealth Prior Authorization Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents PDF None English
DHCAA F-00238 ForwardHealth Prior Authorization Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents Word None English
DHCAA F-00238A ForwardHealth Prior Authorization Drug Attachment for Glucagon-Like Peptide (GLP-1) Agents Completion Instructions PDF None English
DHCAA F-00239 ForwardHealth Prior Authorization for Drug Attachment for Diabetic Supplies PDF None English
DHCAA F-00239 ForwardHealth Prior Authorization for Drug Attachment for Diabetic Supplies Word None English
DHCAA F-00239A ForwardHealth Prior Authorization for Drug Attachment for Diabetic Supplies Completion Instructions PDF None English
DHCAA F-00243 Community Recovery Services Mental Health / Substance Abuse Welcome Enrollment Packet Paper Form Manager English
DHCAA F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information PDF None English
DHCAA F-00250 ForwardHealth Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use PDF None English
DHCAA F-00250 ForwardHealth Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use Word None English
DHCAA F-00279 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Zetia or Vytorin PDF None English
DHCAA F-00279 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Zetia or Vytorin Word None English
DHCAA F-00279A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Zetia or Vytorin Completion Instructions PDF None English
DHCAA F-00280 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents PDF None English
DHCAA F-00280 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents Word None English
DHCAA F-00280A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Migraine Agents Completion Instructions PDF None English
DHCAA F-00281 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents PDF None English
DHCAA F-00281 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents Word None English
DHCAA F-00281A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Fentanyl Mucosal Agents Completion Instructions PDF None English
DHCAA F-00282 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Fibromyalgia PDF None English
DHCAA F-00282 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Fibromyalgia Word None English
DHCAA F-00282A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Fibromyalgia Completion Instructions PDF None English
DHCAA F-00283 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Generalized Anxiety Disorder (GAD) PDF None English
DHCAA F-00283 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Generalized Anxiety Disorder (GAD) Word None English
DHCAA F-00283A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Generalized Anxiety Disorder (GAD) Completion Instructions PDF None English
DHCAA F-00284 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Major Depressive Disorder (MDD) PDF None English
DHCAA F-00284 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Major Depressive Disorder (MDD) Word None English
DHCAA F-00284A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Major Depressive Disorder (MDD) Completion Instructions PDF None English
DHCAA F-00285 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Diabetic Peripheral Neuropathy (DPN) PDF None English
DHCAA F-00285 ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Diabetic Peripheral Neuropathy (DPN) Word None English
DHCAA F-00285A ForwardHealth Prior Authorization / Preferred Drug List (PA / PDL) for Step Therapy for Cymbalta for Diabetic Peripheral Neuropathy (DPN) Completion Instructions PDF None English
DHCAA F-00286 ForwardHealth Attestation to Administer Alpha Hydroxyprogersone (17P) Caproate Injections PDF None English
DHCAA F-00286 ForwardHealth Attestation to Administer Alpha Hydroxyprogersone (17P) Caproate Injections Word None English
DHCAA F-00286A ForwardHealth Attestation to Administer Alpha Hydroxyprogersone (17P) Caproate Injections Completion Instructions PDF None English
DHCAA F-00325 Supplemental Disaster FoodShare Program (DFSP) Affidavit PDF None English
DHCAA F-00325S Supplemental Disaster FoodShare Program (DFSP) Affidavit - Spanish PDF None Spanish
DHCAA F-00330 Request for Replacement FoodShare Benefits PDF None English
DHCAA F-00332 Medicaid Purchase Plan Premium Information / Payment PDF None English
DHCAA F-00333 Information Regarding Your BadgerCare Plus Core Plan Request Word None English
DHCAA F-00341 Community Recovery Services Terms of Reimbursement Paper Form Manager English
DHCAA F-00343 Eligibility Management (Income Maintenance) Policy Notification Sign-Up HTML None English
DHCAA F-00345 ForwardHealth Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services PDF None English
DHCAA F-00345 ForwardHealth 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 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 ForwardHealth Expedited Emergency Supply Request PDF None English
DHCAA F-00401 ForwardHealth Expedited Emergency Supply Request Word None English
DHCAA F-00401A ForwardHealth Expedited Emergency Supply Request Instructions PDF None English
DHCAA F-00402 ForwardHealth Attestation to Prescribe more than one Antipsychotic Drug for a Member 16 Years of Age or Younger PDF None English
DHCAA F-00402 ForwardHealth Attestation to Prescribe more than one Antipsychotic Drug for a Member 16 Years of Age or Younger Word None English
DHCAA F-00402A ForwardHealth Attestation to Prescribe more than one Antipsychotic Drug for a Member 16 Years of Age or Younger Completion Instructions PDF None English
DHCAA F-00407 Financial Records Request PDF None English
DHCAA F-00433 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tables PDF None English
DHCAA F-00433 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tables Word None English
DHCAA F-00433A ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Suspensions and Orally Disintegrating Tables Completion Instructions PDF None English
  F-00508 ForwardHealth Attestation to Administer Makena Injections PDF None English
  F-00508 ForwardHealth Attestation to Administer Makena Injections Word None English
  F-00508A ForwardHealth Attestation to Administer Makena Injections Completion Instructions PDF None English
HCF-01002 F-01002 HealthCheck Individual Health History PDF None English
HCF-01002 F-01002 HealthCheck Individual Health History Word None English
HCF-01002H F-01002H HealthCheck Individual Health History - Hmong PDF None Hmong
HCF-01002S F-01002S HealthCheck Individual Health History - Spanish PDF None Spanish
HCF-01003 F-01003 Wisconsin Medicaid Certification of Public Expenditures PDF None English
HCF-01008 F-01008 Wisconsin Medicaid Notification of Medicaid Hospice Benefit Election PDF None English
HCF-01008 F-01008 Wisconsin Medicaid Notification of Medicaid Hospice Benefit Election Word None English
HCF-01009 F-01009A Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under PDF None English
HCF-01009 F-01009A Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under Word None English
  F-01009AH Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Hmong PDF None Hmong
  F-01009AH Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Hmong Word None Hmong
DHCAA F-01009AS Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Spanish PDF None Spanish
DHCAA F-01009AS Wisconsin Medicaid Election of Hospice Benefit for members 20 and Under - Spanish Word None Spanish
DHCAA F-01009B Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older PDF None English
DHCAA F-01009B Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older Word None English
  F-01009BH Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Hmong PDF None Hmong
  F-01009BH Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Hmong Word None Hmong
  F-01009BS Wisconsin Medicaid Election of Hospice Benefit for members 21 and Older - Spanish PDF None Spanish
  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 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 None English
HCF-01011 F-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness Word None English
HCF-01012 F-01012 ForwardHealth Reimbursement Request for a PASARR Level I Screen PDF None English
HCF-01012 F-01012 ForwardHealth Reimbursement Request for a PASARR Level I Screen Word None English
HCF-01012A F-01012A ForwardHealth Reimbursement Request for a PASARR Level I Screen Instructions PDF None English
HCF-01013 F-01013 ForwardHealth Nurses Aide Training and Competency Test Reimbursement Request PDF None English
HCF-01013 F-01013 ForwardHealth Nurse Aide Training and Competency Test Reimbursement Request Word None English
HCF-01013A F-01013A ForwardHealth Nurses Aide Training and Competency Test Reimbursement Request Instructions PDF None English
HCF-01016 F-01016 ForwardHealth Provider Suggestion PDF None English
HCF-01017 F-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement 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 None English
HCF-01018 F-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers 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 None English
HCF-01050A F-01050A Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions PDF None English
HCF-01058 F-01058 Wisconsin Chronic Renal Disease Program Drug Benefits Important Notice PDF None English
HCF-01062 F-01062 HealthCheck Adolescent Review PDF None English
HCF-01062S F-01062S HealthCheck Adolescent Review - Spanish PDF None Spanish
HCF-01063 F-01063 HealthCheck Family History PDF None English
HCF-01063 F-01063 HealthCheck Family History Word None English
HCF-01063S F-01063S HealthCheck Family History - Spanish 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 None English
HCF-01066A F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age PDF None English
HCF-01066AS F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age - Spanish PDF None Spanish
HCF-01066B F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) PDF None English
HCF-01066BS F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age) - Spanish PDF None Spanish
DHCAA F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age) - Spanish PDF None Spanish
HCF-01067 F-01067 HealthCheck Your Child's Speech and Hearing PDF None English
HCF-01068A F-01068A HealthCheck Age Specific Documentation / General Pediatric Clinic - 3 to 4 Week Visit 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 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 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 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 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 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 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 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 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 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 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 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 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 None Spanish
HCF-01068MS F-01068MS HealthCheck Age Specific Documentation / Confidential Health Survey - Spanish Word None Spanish
DHCAA F-01069 Ambulance Certification Criteria System Provider Services English
DHCAA F-01070 Ambulance Terms of Reimbursement System Provider Services English
DHCAA F-01071 Ambulatory Surgical Center Certification Criteria System Provider Services English
DHCAA F-01072 Ambulatory Surgical Center Terms of Reimbursement System Provider Services English
DHCAA F-01073 Anesthetist Certification Criteria System Provider Services English
DHCAA F-01074 Anesthetist Terms of Reimbursement System Provider Services English
DHCAA F-01077 Audiologist Certification Criteria System Provider Services English
DHCAA F-01078 Hearing Instrument Specialist (Hearing Aid Dealer) Certification Criteria System Provider Services English
DHCAA F-01079 Speech and Hearing Clinic Certification Criteria System Provider Services English
DHCAA F-01080 Speech-Language Pathologist Certification Criteria System Provider Services English
DHCAA F-01081 Speech-Language Pathology Non-Billing Performing Providers Certification Criteria System Provider Services English
DHCAA F-01082 Audiology Terms of Reimbursement System Provider Services English
DHCAA F-01083 Hearing Instrument Specialist Terms of Reimbursement System Provider Services English
DHCAA F-01084 Speech - Language Pathology Therapy Terms of Reimbursement System Provider Services English
DHCAA F-01085 Case Management Certification Criteria System Provider Services English
DHCAA F-01086 Case Management Terms of Reimbursement System Provider Services English
DHCAA F-01087 Chiropractor Certification Criteria System Provider Services English
DHCAA F-01088 Chiropractor Terms of Reimbursement System Provider Services English
DHCAA F-01089 Dental Certification Criteria System Provider Services English
DHCAA F-01090 Clinic Certification Criteria System Provider Services English
DHCAA F-01091 Dental Hygienist Certification Criteria System Provider Services English
DHCAA F-01092 Dental - Dental Hygienists Terms of Reimbursement System Provider Services English
DHCAA F-01093 Dialysis Faculty (End-Stage Renal Disease) Certification Criteria System Provider Services English
DHCAA F-01094 Free Standing End-Stage Renal Disease Provider Terms of Reimbursement System Provider Services English
DHCAA F-01095 Hospital Affiliated End-Stage Renal Disease Provider Terms of Reimbursement System Provider Services English
DHCAA F-01099 Family Planning Clinic Terms of Reimbursement System Provider Services English
DHCAA F-01101 Federally Qualified Health Center Certification Criteria System Provider Services English
HCF-01105 F-01105 Pre-Natal Care Coordination Pregnancy Questionnaire PDF Form Center English
HCF-01105A F-01105A Pre-Natal Care Coordination Pregnancy Questionnaire Completion Instructions PDF None English
HCF-01105H F-01105H Pre-Natal Care Coordination Pregnancy Questionnaire - Hmong PDF None Hmong
HCF-01105S F-01105S Pre-Natal Care Coordination Program Pregnancy Questionnaire - Spanish PDF None Spanish
DHCAA F-01108 Federally Qulified Health Center Terms of Reimbursement Criteria System Provider Services English
HCF-01111A F-01111A Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation System None English
HCF-01112 F-01112 HealthCheck Verification Card Paper Form Center English
DHCAA F-01113 HealthCheck Other Services Provider Terms of Reimbursement System Provider Services English
DHCAA F-01114 HealthCheck Screener and Case Management Provider Terms of Reimbursement System Provider Services English
DHCAA F-01116 HealthCheck Program Overview System Provider Services English
DHCAA F-01117 Wisconsin Medicaid HealthCheck System Provider Services English
HCF-01118 F-01118 ForwardHealth Child Care Coordination Family Questionnaire PDF Form Center English
DHCAA F-01118A ForwardHealth Child Care Coordination Family Questionnaire Completion Instructions PDF None English
DHCAA F-01119 Wisconsin Medicaid Outreach and Case Management Policies System Provider Services English
DHCAA F-01120 Home Health Agency Certification Criteria System Provider Services English
DHCAA F-01121 Home Health Agency Terms of Reimbursement System Provider Services English
DHCAA F-01124 Hospice Certification Criteria System Provider Services English
DHCAA F-01125 Hospice Terms of Reimbursement System Provider Services English
DHCAA F-01126 Wisconsin Medicaid Hospice Certification Criteria System Provider Services English
DHCAA F-01127 Border Status Hospitals Terms of Reimbursement System Provider Services English
DHCAA F-01128 Hospital Terms of Reimbursement System Provider Services English
DHCAA F-01129 Laboratory Certification Criteria System Provider Services English
DHCAA F-01130 Laboratories Terms of Reimbursement System Provider Services English
DHCAA F-01131 Blood Banks Terms of Reimbursement System Provider Services English
DHCAA F-01132 Independent Nurse Certification Criteria System Provider Services English
HCF-01134 F-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit 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 None English
HCF-01144 F-01144 Wisconsin Adult Cystic Fibrosis Program Residency and Health Care Benefits Verification PDF None English
HCF-01145 F-01145 Wisconsin Hemophilia Home Care Program Residency Verification PDF None English
HCF-01146 F-01146 Wisconsin Chronic Disease Program Provider Data Sheet PDF None English
HCF-01149 F-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements 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 ForwardHealth Breast Pump Order PDF None English
HCF-01159 F-01159 ForwardHealth Other Coverage Discrepancy Report PDF None English
HCF-01159 F-01159 ForwardHealth Other Coverage Discrepancy Report Word None English
HCF-01160 F-01160 ForwardHealth Acknowledgement of Receipt of Hysterectomy Information PDF None English
HCF-01160 F-01160 ForwardHealth Acknowledgement of Receipt of Hysterectomy Information Word None English
DHCAA F-01160H ForwardHealth Acknowledgement of Receipt of Hysterectomy Information - Hmong PDF None Hmong
DHCAA F-01160H ForwardHealth Acknowledgement of Receipt of Hysterectomy Information - Hmong Word None Hmong
DHCAA F-01160S ForwardHealth Acknowledgement of Receipt of Hysterectomy Information - Spanish PDF None Spanish
DHCAA F-01160S ForwardHealth Acknowledgement of Receipt of Hysterectomy Information - Spanish Word None Spanish
HCF-01161 F-01161 ForwardHealth Abortion Certification Statements PDF None English
HCF-01161 F-01161 ForwardHealth Abortion Certification Statements Word None English
HCF-01162 F-01162 ForwardHealth Certification of Emergency for Non-U.S. Citizens PDF None English
HCF-01162A F-01162A ForwardHealth Certification of Emergency for Non-U.S. Citizens PDF None English
HCF-01164 F-01164 ForwardHealth Consent for Sterilization PDF None English
HCF-01164 F-01164 ForwardHealth Consent for Sterilization Word None English
HCF-01164A F-01164A ForwardHealth Consent for Sterilization Instructions PDF None English
HCF-01164S F-01164S ForwardHealth Consent for Sterilization - Spanish PDF None Spanish
HCF-01165 F-01165 ForwardHealth Newborn Report PDF None English
HCF-01165 F-01165 ForwardHealth Newborn Report Word None English
HCF-01168 F-01168 ForwardHealth Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases PDF None English
HCF-01168 F-01168 ForwardHealth Special Payment Rate Request for Ventilator - Dependent or Brain Injury Cases Word None English
HCF-01170 F-01170 ForwardHealth Written Correspondence Inquiry PDF None English
HCF-01170 F-01170 ForwardHealth Written Correspondence Inquiry Word None English
HCF-01176 F-01176 ForwardHealth Prior Authorization Fax Cover Sheet PDF None English
HCF-01176 F-01176 ForwardHealth Prior Authorization Fax Cover Sheet Word None English
HCF-01181 F-01181 ForwardHealth Provider Change of Address or Status PDF None English
HCF-01181 F-01181 ForwardHealth Provider Change of Address or Status Word None English
HCF-01181A F-01181A ForwardHealth Provider Change of Address or Status Instructions PDF None English
HCF-01182 F-01182 ForwardHealth Declaration of Supervision for Nonbilling Providers PDF None English
HCF-01182 F-01182 ForwardHealth Declaration of Supervision for Nonbilling Providers Word None English
HCF-01184 F-01184 Wisconsin Hemophilia Home Care Program Application PDF None English
HCF-01184A F-01184A Wisconsin Hemophilia Home Care Program Application Instructions PDF None English
HCF-01185 F-01185 Wisconsin Adult Cystic Fibrosis Program Application PDF None English
HCF-01185A F-01185A Wisconsin Adult Cystic Fibrosis Program Application Instructions PDF None English
HCF-01186 F-01186 Wisconsin Chronic Renal Disease Program Application PDF None English
HCF-01186A F-01186A Wisconsin Chronic Renal Disease Program Application Instructions PDF None English
HCF-01187 F-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement PDF None English
HCF-01187A F-01187A Wisconsin Hemophilia Home Care Program Financial Need Statement Instructions PDF None English
HCF-01188 F-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement PDF None English
HCF-01188A F-01188A Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Instructions PDF None English
HCF-01189 F-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement PDF None English
HCF-01189A F-01189A Wisconsin Chronic Renal Disease Program Financial Need Statement Instructions PDF None English
HCF-01194 F-01194 Wisconsin Chronic Renal Disease Program Financial Need Statement Cover Memo PDF None English
HCF-01195 F-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo PDF None English
HCF-01196 F-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo PDF None English
HCF-01197 F-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation 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 None English
HCF-01198 F-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services 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 None English
HCF-01199 F-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration Word None English
HCF-01300 F-01300 Wisconsin Medicaid Specialized Medical Vehicle Information Chart PDF None English
HCF-01300 F-01300 Wisconsin Medicaid Specialized Medical Vehicle Information Chart Word None English
HCF-01301 F-01301 Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart PDF None English
HCF-01301 F-01301 Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart Word None English
HCF-01302 F-01302 Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report PDF None English
HCF-01302A F-01302A Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report instructions PDF None English
DHCAA F-01501 Private Duty Nursing to Ventilator-Dependent Members Terms of Reimbursement System Provider Services English
DHCAA F-01502 Private Duty Nursing Terms of Reimbursement System Provider Services English
DHCAA F-01504 Nurse Midwife Terms of Reimbursement System Provider Services English
DHCAA F-01505 Durable Medical Equipment and Medical Supplies Certification Criteria System Provider Services English
DHCAA F-01506 Medical Supply and Equipment Vendor Terms of Reimbursement System Provider Services English
DHCAA F-01507 Mental Health / Substance Abuse Services Terms of Reimbursement System Provider Services English
DHCAA F-01508 Nurse Practitioner Certification Criteria System Provider Services English
DHCAA F-01509 Nurse Practitioner Terms of Reimbursement System Provider Services English
DHCAA F-01511 Occupational Therapist and Assistant Certification Criteria System Provider Services English
DHCAA F-01512 Occupational Therapy Terms of Reimbursement System Provider Services English
DHCAA F-01513 Optician / Optometrist's Certification Criteria System Provider Services English
DHCAA F-01514 Optometrist / Optician Terms of Reimbursement System Provider Services English
DHCAA F-01515 Personal Care Provider Certification Criteria System Provider Services English
DHCAA F-01516 Personal Care Terms of Reimbursement System Provider Services English
DHCAA F-01517 Pharmacy Certification Criteria System Provider Services English
DHCAA F-01518 Pharmacy Terms of Reimbursement System Provider Services English
DHCAA F-01519 Physical Therapy and Assistants Certification Criteria System Provider Services English
DHCAA F-01520 Physical Therapy Terms of Reimbursement System Provider Services English
DHCAA F-01521 Physician Certification Criteria System Provider Services English
DHCAA F-01522 Physician Assistant Certification Criteria System Provider Services English
DHCAA F-01523 Physician and Physician Assistant Terms of Reimbursement System Provider Services English
DHCAA F-01524 Podiatrist Certification Criteria System Provider Services English
DHCAA F-01525 Podiatrist Terms of Reimbursement System Provider Services English
DHCAA F-01526 Portable X-Ray Provider Certification Criteria System Provider Services English
DHCAA F-01527 Portable X-Ray Terms of Reimbursement System Provider Services English
DHCAA F-01528 PreNatal Care Coordination Certification Criteria System Provider Services English
DHCAA F-01529 PreNatal Care Coordination Agency Terms of Reimbursement System Provider Services English
DHCAA F-01530 Rehabilitation Agency Certification Criteria System Provider Services English
DHCAA F-01531 Rehabilitation Agency Terms of Reimbursement System Provider Services English
DHCAA F-01532 Rural Health Clinic Certification Criteria System Provider Services English
DHCAA F-01533 Rural Health Clinic Terms of Reimbursement System Provider Services English
DHCAA F-01534 School-Based Services Certification Criteria System Provider Services English
DHCAA F-01535 School-Based Services Terms of Reimbursement System Provider Services English
DHCAA F-01536 Specialized Medical Vehicle Transportation Services Certification System Provider Services English
DHCAA F-01537 Specialized Medical Vehicle Terms of Reimbursement System Provider Services English
DHCAA F-01540 Wisconsin Chronic Disease Program Provider Application and Instructions System Provider Services English
DHCAA F-01541 Wisconsin Chronic Disease Program Provider Agreement and Acknowledgement of Terms of Participation (Standard for Individual and Clinic / Group / Agency Providers) System Provider Services English
HCF-10075 F-10075 Wisconsin Well Woman Medicaid Determination PDF Form Center English
HCF-10076 F-10076 SeniorCare Application PDF Form Center English
HCF-10076A F-10076A SeniorCare Instructions for Application Form PDF Form Center English
HCF-10076AH F-10076AH SeniorCare Instructions for Application Form - Hmong PDF None Hmong
HCF-10076AS F-10076AS SeniorCare Instructions for Application Form - Spanish PDF None Spanish
HCF-10080 F-10080 SeniorCare Authorization of Representative 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 None English
HCF-10093 F-10093 Medicaid / BadgerCare Plus Overpayment Notice PDF None English
HCF-10093S F-10093S Medicaid / BadgerCare Overpayment Notice - Spanish PDF None Spanish
HCF-10095 F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse PDF None English
HCF-10095S F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse - Spanish PDF None Spanish
HCF-10096 F-10096 Community Spouse Asset Share Notice PDF None English
DHCAA F-10096S Community Spouse Asset Share Notice - Spanish PDF None Spanish
HCF-10097 F-10097 Medicaid Income Allocation Notice PDF None English
DHCAA F-10097S Medicaid Income Allocation Notice - Spanish PDF None Spanish
HCF-10098 F-10098 Medicaid Member Asset Allocation Notice PDF None English
DHCAA F-10098S Medicaid Member Asset Allocation Notice - Spanish PDF None Spanish
HCF-10099 F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility PDF None English
HCF-10101 F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet PDF Form Center English
HCF-10101H F-10101H Wisconsin Medicaid for the Elderly, Blind or Disabled Application / Review Packet - Hmong PDF None Hmong
HCF-10101S F-10101S Wisconsin Medicaid Health Care for the Elderly, Blind and Disabled Application / Review Packet - Spanish 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 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 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 None English
DHCAA 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 None Spanish
HCF-10108 F-10108 Medicaid Manual Notice for Cost of Care Contribution PDF None English
HCF-10108A F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions PDF None English
HCF-10109 F-10109 Medicaid Remaining Deductible Update PDF Form Center English
HCF-10110 F-10110 Medicaid / BadgerCare Plus Certification System None English
HCF-10111 F-10111 Good Faith Medicaid / BadgerCare Plus Certification PDF None English
HCF-10111A F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions PDF None English
HCF-10112 F-10112 Medicaid Disability Application PDF Form Center English
HCF-10112S F-10112S Medicaid Disability Application - Spanish PDF None Spanish
HCF-10114 F-10114 Medicaid Disability Redetermination Report PDF None English
HCF-10115 F-10115 BadgerCare Plus / Medicaid Health Insurance Information PDF None English
HCF-10115S F-10115S BadgerCare Plus / Medicaid Health Insurance Information - Spanish 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 None English
HCF-10121 F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration PDF None English
HCF-10122 F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information PDF None English
HCF-10126 F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative PDF None English
HCF-10126H F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong PDF None Hmong
HCF-10126S F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish PDF None Spanish
HCF-10127 F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  PDF None English
HCF-10129 F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application PDF None English
HCF-10129H F-10129H Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong PDF None Hmong
HCF-10129S F-10129S Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish PDF None Spanish
HCF-10130 F-10130 Medicaid Presumptive Disability PDF None English
HCF-10137 F-10137 Medicaid Change Report PDF Form Center English
HCF-10137H F-10137H Medicaid Change Report - Hmong PDF None Hmong
HCF-10137R F-10137R Medicaid Change Report - Russian PDF None Russian
HCF-10137S F-10137S Medicaid Change Report - Spanish PDF None Spanish
HCF-10138 F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application PDF None English
HCF-10139 F-10139 BadgerCare Plus Premium Information PDF None English
HCF-10139S F-10139S BadgerCare Plus Premium Information - Spanish PDF None Spanish
HCF-10140 F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application PDF None English
HCF-10140S F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish PDF None Spanish
HCF-10141 F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request PDF None English
HCF-10141A F-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF None English
HCF-10142 F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant PDF None English
HCF-10143 F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice 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 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 None English
HCF-10148 F-10148 Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children PDF None English
HCF-10148 F-10148 Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children Word None English
HCF-10150 F-10150 Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin PDF None English
HCF-10150S F-10150S Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare Plus and FoodShare Wisconsin - Spanish PDF None Spanish
HCF-10151 F-10151 Medicaid / BadgerCare Plus Fair Hearing Information PDF None English
HCF-10154 F-10154 Statement of Identity for Children Under 18 Years of Age PDF None English
HCF-10154H F-10154H Statement of Identity for Children Under 18 Years of Age - Hmong PDF None Hmong
HCF-10154R F-10154R Statement of Identity for Children Under 18 Years of Age - Russian PDF None Russian
HCF-10154S F-10154S Statement of Identity for Children Under 18 Years of Age - Spanish PDF None Spanish
HCF-10161 F-10161 Statement of Citizenship and / or Identity for Special Populations PDF None English
HCF-10162 F-10162 Verification of Veterans Benefits PDF None English
HCF-10171 F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding PDF None English
HCF-10172 F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding PDF None English
HCF-10175 F-10175 Statement of Identity for Persons in Institutional Care Facilities PDF None English
HCF-10176 F-10176 BadgerCare Plus Express Enrollment Change Request for Partners / Providers PDF None English
HCF-10176 F-10176 BadgerCare Plus Express Enrollment Change Request for Partners / Providers Word None English
HCF-10177 F-10177 Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women PDF None English
HCF-10177 F-10177 Application to become a Certified Provider for BadgerCare Plus Express Enrollment for Pregnant Women Word None English
HCF-10180 F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version PDF None English
HCF-10182 F-10182 BadgerCare Plus Application / Review Packet PDF Form Center English
HCF-10182H F-10182H BadgerCare Plus Application Packet - Hmong PDF None Hmong
HCF-10182S F-10182S BadgerCare Plus Application / Review Packet - Spanish PDF None Spanish
HCF-10183 F-10183 BadgerCare Plus Change Report PDF Form Center English
HCF-10183H F-10183H BadgerCare Plus Change Report - Hmong PDF Form Center Hmong
HCF-10183S F-10183S BadgerCare Plus Change Report - Spanish PDF Form Center Spanish
HCF-10184 F-10184 BadgerCare Plus Youth Exiting Out-of-Home Care (YEOHC) Word None English
HCF-10185 F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication Word None English
HCF-10186 F-10186 Designation of a BadgerCare Plus Essential Person PDF None English
DHCAA F-10187 ForwardHealth Divestment Penalty and Undue Hardship Notice Word None English
DHCAA F-10188 ForwardHealth Undue Hardship Waiver Decision Word None English
DHCAA F-10189 ForwardHealth Undue Hardship Bedhold Notice Word None English
DHCAA F-10190 ForwardHealth Issuer of Annuity - Notice of Obligation PDF None English
DHCAA F-10191 ForwardHealth Annuity Beneficiary Designation PDF None English
DHCAA F-10192 ForwardHealth Annuity Information Disclosure PDF None English
DHCAA F-10193 ForwardHealth Undue Hardship Request PDF None English
HCF-11001 F-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet PDF None English
HCF-11001 F-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet Word None English
DHCAA F-11001A Wisconsin Medicaid Out-of-State Provider Data Sheet Completion Instructions PDF None English
HCF-11002 F-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet PDF None English
HCF-11002 F-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet Word None English
DHCAA F-11002A Wisconsin Medicaid In-State Emergency Provider Data Sheet Completion Instructions PDF None English
HCF-11003 F-11003 ForwardHealth Provider Application Information and Instructions System Provider Services English
HCF-11004 F-11004 ForwardHealth Provider Application Mental Health Substance Abuse Agency Services Information and Instructions System Provider Services English
HCF-11005 F-11005 Wisconsin Medicaid Provider Application Mental Health Substance Abuse Individual Services (for Non-Physicians) Information and Instructions System Provider Services English
HCF-11007 F-11007 Wisconsin Medicaid Nursing Home Provider Application Information and Instructions System Provider Services English
HCF-11008 F-11008 ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) PDF None English
HCF-11008 F-11008 ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) Word None English
HCF-11008A F-11008A ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) Completion Instructions PDF None English
HCF-11010 F-11010 ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format PDF None English
HCF-11010 F-11010 ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format Word None English
HCF-11010A F-11010A ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Completion Instructions PDF None English
HCF-11011 F-11011 ForwardHealth Prior Authorization / Birth to 3 Attachment (PA/B3) PDF None English
HCF-11011 F-11011 ForwardHealth Prior Authorization / Birth to 3 Attachment (PA/B3) Word None English
HCF-11013 F-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet PDF None English
HCF-11013 F-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet Word None English
HCF-11013A F-11013A Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet Completion Instructions PDF None English
HCF-11014 F-11014 ForwardHealth Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services PDF None English
HCF-11014 F-11014 ForwardHealth Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services Word None English
HCF-11016 F-11016 ForwardHealth Prior Authorization Physician Attachment (PA/PA) PDF None English
HCF-11016 F-11016 ForwardHealth Prior Authorization Physician Attachment (PA/PA) Word None English
HCF-11016A F-11016A ForwardHealth Prior Authorization Physician Attachment (PA/PA) Completion Instructions PDF None English
HCF-11017 F-11017 Wisconsin Medicaid Hospital Provider Application Information and Instructions System Provider Services English
HCF-11018 F-11018 ForwardHealth Prior Authorization Request Form (PA/RF) PDF None English
HCF-11018 F-11018 ForwardHealth Prior Authorization Request Form (PA/RF) Word None English
HCF-11019 F-11019 ForwardHealth Prior Authorization / Physician Otological Report (PA/POR) PDF None English
HCF-11019 F-11019 ForwardHealth Prior Authorization / Physician Otological Report (PA/POR) Word None English
HCF-11019A F-11019A ForwardHealth Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions PDF None English
HCF-11020 F-11020 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) PDF None English
HCF-11020 F-11020 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Word None English
HCF-11020A F-11020A ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) Completion Instructions PDF None English
HCF-11021 F-11021 ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services PDF None English
HCF-11021 F-11021 ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) Word None English
HCF-11021A F-11021A ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services Completion Instructions PDF None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data PDF None English
HCF-11023 F-11023 Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Excel None English
HCF-11023A F-11023A Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Completion Instructions PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs Word None English
HCF-11025A F-11025A Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs Instructions PDF None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs PDF None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Word None English
HCF-11026A F-11026A Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Completion Instructions PDF None English
HCF-11027 F-11027 Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Excel None English
HCF-11027A F-11027A Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Instructions PDF None English
HCF-11029 F-11029 ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) PDF None English
HCF-11029 F-11029 ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) Word None English
HCF-11029A F-11029A ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) Completion Instructions PDF None English
HCF-11030 F-11030 ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) PDF None English
HCF-11030 F-11030 ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Word None English
HCF-11030A F-11030A ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Completion Instructions PDF None English
HCF-11031 F-11031 ForwardHealth Prior Authorization / Psychotherapy Attachment (PA/PSYA) PDF None English
HCF-11031 F-11031 ForwardHealth Prior Authorization / Psychotherapy Attachment (PA/PSYA) Word None English
HCF-11031A F-11031A ForwardHealth Prior Authorization / Psychotherapy Attachment (PA / PSYA) Completion Instructions PDF None English
HCF-11032 F-11032 ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) PDF None English
HCF-11032 F-11032 ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) Word None English
HCF-11032A F-11032A ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) Instructions PDF None English
HCF-11033 F-11033 ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) PDF None English
HCF-11033 F-11033 ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Word None English
HCF-11033A F-11033A ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Completion Instructions PDF None English
HCF-11034 F-11034 ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) PDF None English
HCF-11034 F-11034 ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) Word None English
HCF-11034A F-11034A ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) Completion Instructions PDF None English
HCF-11035 F-11035 ForwardHealth Prior Authorization Dental Request (PA / DRF) PDF None English
HCF-11035 F-11035 ForwardHealth Prior Authorization Dental Request Form Word None English
HCF-11035A F-11035A ForwardHealth Prior Authorization Dental Request Form [PA / DRF] Completion Instructions PDF None English
HCF-11036 F-11036 ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) PDF None English
HCF-11036 F-11036 ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) Word None English
HCF-11036A F-11036A ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA/ITA) Completion Instructions PDF None English
HCF-11037 F-11037 ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) PDF None English
HCF-11037 F-11037 ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Word None English
HCF-11037A F-11037A ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Instructions PDF None English
HCF-11038 F-11038 ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) PDF None English
HCF-11038 F-11038 ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Word None English
HCF-11038A F-11038A ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Instructions PDF None English
HCF-11039 F-11039 ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) PDF None English
HCF-11039 F-11039 ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) Word None English
HCF-11039A F-11039A ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) Completion Instructions PDF None English
HCF-11040 F-11040 ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) PDF None English
HCF-11040 F-11040 ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Word None English
HCF-11040A F-11040A ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Completion Instructions PDF None English
HCF-11041 F-11041 ForwardHealth Private Duty Nursing Prior Authorization Acknowledgment PDF None English
HCF-11041 F-11041 ForwardHealth Private Duty Nursing Prior Authorization Acknowledgment Word None English
HCF-11042 F-11042 ForwardHealth Prior Authorization Amendment Request PDF None English
HCF-11042 F-11042 ForwardHealth Prior Authorization Amendment Request Word None English
HCF-11042A F-11042A ForwardHealth Prior Authorization Amendment Request Completion Instructions PDF None English
HCF-11044 F-11044 ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) PDF None English
HCF-11044 F-11044 ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Word None English
HCF-11044A F-11044A ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Completion Instructions PDF None English
HCF-11047 F-11047 Wisconsin Medicaid Certification of Need for Elective / Urgent Psychiatric / Substance Abuse PDF None English
HCF-11048 F-11048 Wisconsin Medicaid Certification of Need for Emergency Psychiatric / Substance Abuse Admission to Hospital Institutions for Mental Disease for Members Under Age 21 and in Case of Medicaid Determination after Admission PDF None English
HCF-11049 F-11049 ForwardHealth Prior Authorization / Drug Attachment (PA/DGA) PDF None English
HCF-11049 F-11049 ForwardHealth Prior Authorization / Drug Attachment (PA/DGA) Word None English
HCF-11049A F-11049A ForwardHealth Prior Authorization / Drug Attachment (PA/DGA) Completion Instructions PDF None English
HCF-11051 F-11051 ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) PDF None English
HCF-11051 F-11051 ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) Word None English
HCF-11051A F-11051A ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) Completion Instructions PDF None English
HCF-11052 F-11052 ForwardHealth STAT-PA Orthopedic Shoes Worksheet PDF None English
HCF-11052 F-11052 ForwardHealth STAT-PA Orthopedic Shoes Worksheet Word None English
HCF-11052A F-11052A ForwardHealth STAT-PA Orthopedic Shoes Worksheet Completion Instructions PDF None English
HCF-11054 F-11054 ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) PDF None English
HCF-11054 F-11054 ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Word None English
HCF-11054A F-11054A ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Completion Instructions PDF None English
HCF-11055 F-11055 ForwardHealth STAT-PA System Instructions PDF None English
HCF-11056 F-11056 ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors PDF None English
HCF-11056 F-11056 ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors Word None English
HCF-11056A F-11056A ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors Completion Instructions PDF None English
HCF-11062 F-11062 ForwardHealth Prior Authorization / Environmental Lead Inspection PDF None English
HCF-11062 F-11062 ForwardHealth Prior Authorization / Environmental Lead Inspection Word None English
HCF-11062A F-11062A ForwardHealth Prior Authorization / Environmental Lead Inspection Instructions for Paper Prior Authorization or STAT-PA PDF None English
HCF-11066 F-11066 ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) PDF None English
HCF-11066 F-11066 ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) Word None English
HCF-11066A F-11066A ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) Completion Instructions PDF None English
HCF-11067 F-11067 ForwardHealth Record of Actual Daily Oxygen Use PDF None English
HCF-11067 F-11067 ForwardHealth Record of Actual Daily Oxygen Use Word None English
HCF-11067A F-11067A ForwardHealth Record of Actual Daily Oxygen Use Completion Instructions PDF None English
HCF-11075 F-11075 ForwardHealth Prior Authorization / Preferred Drug List (PA PDL) Exemption Request PDF None English
HCF-11075 F-11075 ForwardHealth Prior Authorization / Preferred Drug List (PA PDL) Exemption Request Word None English
HCF-11075A F-11075A ForwardHealth Prior Authorization / Preferred Drug List (PA PDL) Exemption Request Completion Instructions PDF None English
HCF-11076 F-11076 ForwardHealth Prior Authorization Request (PA / RF) Completion Instructions for Residential Care Center Treatment Services PDF None English
HCF-11076A F-11076A ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC PDF None English
HCF-11076A F-11076A ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC Word None English
HCF-11076B F-11076B ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services PDF None English
HCF-11076B F-11076B ForwardHealth Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services Word None English
HCF-11076C F-11076C ForwardHealth Prior Authorization / Residential Care Center Treatment Attachment (PA / RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services PDF None English
HCF-11077 F-11077 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors PDF None English
HCF-11077 F-11077 ForwardHealth 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 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) Including Cyclo-Oxygenase Inhibitors Completion Instructions PDF None English
HCF-11078 F-11078 ForwardHealth BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs PDF None English
HCF-11078 F-11078 ForwardHealth BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Word None English
HCF-11078A F-11078A ForwardHealth BadgerCare Plus Prior Authorization / Preferred Drug List (PA/PDL) for Proton Pump Inhibitor (PPI) Drugs Completion Instructions PDF None English
HCF-11079 F-11079 Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Excel None English
HCF-11079A F-11079A Wisconsin Medicaid Cost Report for Independent and Provider-Based (Affiliated Hospital Having More than 50 Beds) Rural Health Clinics Completion Instructions PDF None English
HCF-11080 F-11080 Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Excel None English
HCF-11080A F-11080A Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Completion Instructions PDF None English
DHCAA F-11080CA Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Completion Instructions PDF None English
DHCAA F-11080CP Wisconsin Medicaid Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) (30% overhead applicable for RHC Services) Excel None English
HCF-11081 F-11081 Wisconsin Medicaid Rural Health Clinic Provider Staff Encounters Excel None English
HCF-11083 F-11083 ForwardHealth Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) PDF None English
HCF-11083 F-11083 ForwardHealth Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) Word None English
HCF-11083A F-11083A ForwardHealth Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) Completion Instructions PDF None English
HCF-11088 F-11088 ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) PDF None English
HCF-11088 F-11088 ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Word None English
HCF-11088A F-11088A ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Completion Instructions PDF None English
HCF-11090 F-11090 ForwardHealth Mental Health Day Treatment Functional Assessment PDF None English
HCF-11090 F-11090 ForwardHealth Mental Health Day Treatment Functional Assessment Word None English
HCF-11090A F-11090A ForwardHealth Mental Health Day Treatment Functional Assessment Completion Instructions PDF None English
HCF-11092 F-11092 ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs PDF None English
HCF-11092 F-11092 ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Word None English
HCF-11092A F-11092A ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Completion Instructions PDF None English
HCF-11096 F-11096 ForwardHealth Prior Authorization / Care Plan Attachment (for dates of service on or after May 1, 2010) PDF None English
HCF-11096 F-11096 ForwardHealth Prior Authorization / Care Plan Attachment (for dates of service on or after May 1, 2010) Word None English
HCF-11096A F-11096A ForwardHealth Prior Authorization / Care Plan Attachment Completion Instructions (for dates of service on or after May 1, 2010) PDF None English
HCF-11097 F-11097 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents PDF None English
HCF-11097 F-11097 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents Word None English
HCF-11097A F-11097A ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents Completion Instructions PDF None English
HCF-11103 F-11103 ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan PDF None English
HCF-11103 F-11103 ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Word None English
HCF-11103A F-11103A ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Completion Instructions PDF None English
HCF-11129A F-11129A Wisconsin Medicaid Federally Qualified Health Center Cost Report Completion Instructions PDF None English
HCF-11129B-H F-11129B-H Wisconsin Medicaid Federally Qualified Health Center Cost Report Forms Excel None English
HCF-11130 F-11130 Wisconsin Medicaid Federally Qualified Health Center Interim Report Excel None English
HCF-11130A F-11130A Wisconsin Medicaid Federally Qualified Health Center Interim Report Completion Instructions PDF None English
HCF-11133 F-11133 ForwardHealth Personal Care Screening Tool (PCST) PDF None English
HCF-11133 F-11133 ForwardHealth Personal Care Screening Tool (PCST) Word None English
HCF-11133A F-11133A ForwardHealth Personal Care Screening Tool (PCST) Completion Instructions PDF None English
HCF-11134 F-11134 ForwardHealth Personal Care Prior Authorization Provider Acknowledgement PDF None English
HCF-11134 F-11134 ForwardHealth Personal Care Prior Authorization Provider Acknowledgement Word None English
HCF-11136 F-11136 ForwardHealth Personal Care Addendum PDF None English
HCF-11136 F-11136 ForwardHealth Personal Care Addendum Word None English
HCF-11136A F-11136A ForwardHealth Personal Care Addendum Completion Instructions PDF None English
DHCAA F-11183 Letter - Pharmacy Services Lock-In Program / Member Referral PDF None English
HCF-11183 F-11183 ForwardHealth Pharmacy Services Lock-In Program Member Referral to Another Provider for Services Word None English
HCF-11233 F-11233 Wisconsin Medicaid Ambulance Provider Certification Packet System Provider Services English
  F-11234 Wisconsin Medicaid General Certification Information System Provider Services English
HCF-11235 F-11235 Wisconsin Medicaid Ambulatory Surgery Center Provider Certification Packet System Provider Services English
HCF-11236 F-11236 Wisconsin Medicaid Anesthetist Provider Certification Packet System Provider Services English
HCF-11238 F-11238 Wisconsin Medicaid Audiology / Hearing Instrument Specialist / Speech Pathology Provider Certification Packet System Provider Services English
HCF-11239 F-11239 Wisconsin Medicaid Case Management Certification Packet System Provider Services English
HCF-11240 F-11240 Wisconsin Medicaid Case Management Provider Information System Provider Services English
HCF-11241 F-11241 Wisconsin Medicaid Chiropractic Certification Packet System Provider Services English
HCF-11242 F-11242 Wisconsin Medicaid Dental Certification Packet System Provider Services English
HCF-11243 F-11243 Wisconsin Medicaid End Stage Renal Disease Certification Packet System Provider Services English
HCF-11244 F-11244 Wisconsin Medicaid Family Planning Clinics Certification Packet System Provider Services English
HCF-11245 F-11245 Wisconsin Medicaid Family Planning Clinics or Agencies System Provider Services English
HCF-11246 F-11246 Wisconsin Medicaid Federally Qualified Health Center (FQHC) Certification Packet System Provider Services English
HCF-11247 F-11247 Services that can be billed under the Federally Qualified Health Center Clinic Number System Provider Services English
HCF-11248 F-11248 Services that can be billed under the Federally Qualified Health Center Assigned Clinic Number System Provider Services English
HCF-11249 F-11249 Wisconsin Medicaid HealthCheck (Other) Certification Packet System Provider Services English
HCF-11250 F-11250 Wisconsin Medicaid HealthCheck Screener Only Provider Certification Packet System Provider Services English
HCF-11251 F-11251 Wisconsin Medicaid Home Health Agency Provider Certification Packet System Provider Services English
DHCAA F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum System Provider Services English
HCF-11253 F-11253 Wisconsin Medicaid Hospice Provider Certification Packet System Provider Services English
HCF-11254 F-11254 Wisconsin Medicaid Hospital Provider Certification Packet System Provider Services English
HCF-11255 F-11255 Wisconsin Medicaid Independent Laboratory Certification Packet System Provider Services English
HCF-11256 F-11256 Wisconsin Medicaid Independent Nurse Certification Packet System Provider Services English
HCF-11257 F-11257 Wisconsin Medicaid Private Duty Nurse (PDN) Provider Addendum System Provider Services English
DHCAA F-11258 Letter - Provider Services / Private Duty Nursing For Ventilator (Adult) PDF None English
DHCAA F-11259 Letter - Provider Services / Private Duty Nursing For Ventilator (Pediatric) PDF None English
DHCAA F-11260 Wisconsin Medicaid Degree Addendum System Provider Services English
HCF-11261 F-11261 Wisconsin Medicaid Medical Supply and Equipment Vendor Certification Packet System Provider Services English
HCF-11263 F-11263 Wisconsin Medicaid Mental Health Substance Abuse Individual Provider Certification Packet System Provider Services English
HCF-11264 F-11264 Wisconsin Medicaid Nurse Practitioner Provider Certification Packet System Provider Services English
HCF-11265 F-11265 Wisconsin Medicaid Nursing Home Provider Certification Packet System Provider Services English
HCF-11266 F-11266 Wisconsin Medicaid Occupational Therapy Provider Certification Packet System Provider Services English
HCF-11267 F-11267 Wisconsin Medicaid Mental Health Substance Abuse Agency Provider Certification Packet System Provider Services English
HCF-11268 F-11268 Wisconsin BadgerCare Plus Express Enrollment for Pregnant Women Certification Packet System Provider Services English
HCF-11270 F-11270 Wisconsin Medicaid Personal Care Agency Provider Certification Packet System Provider Services English
HCF-11271 F-11271 Wisconsin Medicaid Personal Care Addendum System Provider Services English
HCF-11272 F-11272 Wisconsin Medicaid Pharmacy Provider Certification Packet System Provider Services English
HCF-11273 F-11273 Wisconsin Medicaid Physician Therapy Certification Packet System Provider Services English
HCF-11274 F-11274 Wisconsin Medicaid Physician / Physician Assistant Certification Packet System Provider Services English
HCF-11275 F-11275 Wisconsin Medicaid Podiatry Certification Packet System Provider Services English
HCF-11276 F-11276 Wisconsin Medicaid Portable X-Ray Certification Packet System Provider Services English
HCF-11277 F-11277 Wisconsin Medicaid Pre-Natal Care Coordination Certification Packet System Provider Services English
HCF-11278 F-11278 Wisconsin Medicaid PreNatal Care Coordination Outreach and Management Plan System Provider Services English
DHCAA F-11279 Wisconsin Medicaid Memorandum of Understanding (Sample Format) Between HMO and PreNatal Care Coordination Agency System Provider Services English
HCF-11280 F-11280 Wisconsin Medicaid Rehabilitation Agency Certification Packet System Provider Services English
HCF-11281 F-11281 Wisconsin Medicaid Rural Health Clinic Certification Packet System Provider Services English
HCF-11282 F-11282 Wisconsin Medicaid School-Based Services Certification Packet System Provider Services English
HCF-11284 F-11284 Wisconsin Medicaid Specialized Medical Vehicle Certification Packet System Provider Services English
HCF-11285 F-11285 Wisconsin Medicaid HealthCheck Screener Affirmation System Provider Services English
HCF-11286 F-11286 Wisconsin Medicaid HealthCheck Screener Outreach Case Management Provider Certification Packet System Provider Services English
HCF-11288 F-11288 Wisconsin Medicaid Therapy Group Certification Packet System Provider Services English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan System Provider Services English
HCF-11290 F-11290 Wisconsin Medicaid HealthCheck Outreach Case Management Only Provider Certification Packet System Provider Services English
  F-11295 Blood Banks Certification Criteria System Provider Services English
  F-11296 Wisconsin Medicaid SMV Transportation Service Informational System Provider Services English
HCF-11303 F-11303 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic PDF None English
HCF-11303 F-11303 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic Word None English
HCF-11303A F-11303A ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic Completion Instructions PDF None English
HCF-11304 F-11304 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis PDF None English
HCF-11304 F-11304 ForwardHealth 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 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ankylosing Spondylitis Completion Instructions PDF None English
HCF-11305 F-11305 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease PDF None English
HCF-11305 F-11305 ForwardHealth 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 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Crohn's Disease Completion Instructions PDF None English
HCF-11306 F-11306 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis PDF None English
HCF-11306 F-11306 ForwardHealth 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 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriasis Completion Instructions PDF None English
HCF-11307 F-11307 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis PDF None English
HCF-11307 F-11307 ForwardHealth 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 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Psoriatic Arthritis Completion Instructions PDF None English
HCF-11308 F-11308 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis PDF None English
HCF-11308 F-11308 ForwardHealth 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 ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Plaque Rheumatoid Arthritis Completion Instructions PDF None English
DHCAA F-11309 Wisconsin BadgerCare Plus Express Enrollment for All Children Certification Packet System Provider Services English
HCF-11317 F-11317 ForwardHealth Certification Criteria For Providers Express Enrollment of Pregnant Women in BadgerCare Plus PDF None English
HCF-11318 F-11318 ForwardHealth Certification Criteria For Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus PDF None English
HCF-12022 F-12022 Wisconsin Medicaid and BadgerCare Plus Managed Care Program Provider Appeal 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-12081 F-12081 Wisconsin Medicaid Health Information Exchange Facility Security and Confidentiality Agreement Paper Form Manager English
HCF-12085 F-12085 BadgerCare Plus HMO Program HMO Enrollment Choice Paper Form Manager 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 None English
HCF-13024 F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  PDF None English
HCF-13025 F-13025 BadgerCare Plus Premium Employer Wage Withholding PDF None English
HCF-13026 F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer PDF None English
HCF-13033 F-13033 Probate Claims Notice 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 None English
HCF-13039A F-13039A Estate Recovery Program (ERP) Disclosure Instructions PDF None English
HCF-13046 F-13046 ForwardHealth Adjustment / Reconsideration Request PDF None English
HCF-13046 F-13046 ForwardHealth Adjustment / Reconsideration Request Word None English
HCF-13046A F-13046A ForwardHealth Adjustment / Reconsideration Request Completion Instructions PDF None English
HCF-13047 F-13047 ForwardHealth Timely Filing Appeals Request PDF None English
HCF-13047 F-13047 ForwardHealth Timely Filing Appeals Request Word None English
HCF-13066 F-13066 Wisconsin Medicaid Claim Refund PDF None English
HCF-13066 F-13066 Wisconsin Medicaid Claim Refund Word None English
HCF-13066A F-13066A Wisconsin Medicaid Claim Refund Completion Instructions PDF None English
HCF-13072 F-13072 Noncompound Drug Claim PDF None English
HCF-13072 F-13072 Noncompound Drug Claim Word None English
HCF-13072A F-13072A Noncompound Drug Claim Completion Instructions PDF None English
HCF-13073 F-13073 Compound Drug Claim PDF None English
HCF-13073 F-13073 Compound Drug Claim Word None English
HCF-13073A F-13073A Compound Drug Claim Completion Instructions PDF None English
HCF-13074 F-13074 ForwardHealth Pharmacy Special Handling Request PDF None English
HCF-13074 F-13074 ForwardHealth Pharmacy Special Handling Request Word None English
HCF-13074A F-13074A ForwardHealth Pharmacy Special Handling Request Completion Instructions PDF None English
HCF-13145 F-13145 Wisconsin Medicaid HIPAA Privacy Authorization for Use or Disclosure PDF None English
HCF-13146 F-13146 Wisconsin Medicaid HIPAA Privacy Revocation of Authorization PDF None English
HCF-13147 F-13147 Wisconsin Medicaid HIPAA Privacy Restriction Request PDF None English
HCF-13148 F-13148 Wisconsin Medicaid HIPAA Privacy Access Request PDF None English
HCF-13149 F-13149 Wisconsin Medicaid HIPAA Privacy Accounting Request PDF None English
HCF-13150 F-13150 Wisconsin Medicaid HIPAA Privacy Alternate Communication Request PDF None English
HCF-13151 F-13151 Wisconsin Medicaid HIPAA Privacy Amendment Request PDF None English
HCF-13152 F-13152 Wisconsin Medicaid HIPAA Privacy Complaint PDF None English
HCF-13153 F-13153 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Authorization for Use or Disclosure PDF None English
HCF-13154 F-13154 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request PDF None English
HCF-13155 F-13155 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Accounting Request PDF None English
HCF-13156 F-13156 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Alternate Communication Request PDF None English
HCF-13157 F-13157 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request PDF None English
HCF-13158 F-13158 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Complaint PDF None English
HCF-13159 F-13159 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Restriction Request PDF None English
HCF-13160 F-13160 Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Revocation of Authorization PDF None English
HCF-13161 F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure PDF None English
HCF-13162 F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request PDF None English
HCF-13163 F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request PDF None English
HCF-13164 F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request PDF None English
HCF-13165 F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request PDF None English
HCF-13166 F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint PDF None English
HCF-13167 F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization PDF None English
HCF-13168 F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request PDF None English
HCF-13174 F-13174 Estate Recovery Program Heir Information PDF None English
HCF-13175