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Forms: Numeric List 
F-10000 Through F-19999

This alphabetical 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
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-10172 F-10172 Agency Response to the State Quality Assurance (QA) Medicaid 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 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-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-11008 F-11008 Prior Authorization / Therapy Attachment (PA/TA) (PDF, 83 KB) PDF None English
HCF-11008 F-11008 Prior Authorization / Therapy Attachment (PA/TA) Word None English
HCF-11008A F-11008A Prior Authorization / Therapy Attachment (PA/TA) Completion Instructions (PDF, 98 KB) PDF None English
HCF-11010 F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format (PDF, 253 KB) PDF None English
HCF-11010 F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format Word None English
HCF-11010A F-11010A Prior Authorization / Dental Attachment 1 (PA/DA1) Completion Instructions (PDF, 31 KB) PDF None English
HCF-11011 F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) (PDF, 48 KB) PDF None English
HCF-11011 F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) Word None English
HCF-11014 F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services (PDF, 67 KB) PDF None English
HCF-11014 F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services Word None English
HCF-11016 F-11016 Prior Authorization Physician Attachment (PA/PA) (PDF, 50 KB) PDF None English
HCF-11016 F-11016 Prior Authorization Physician Attachment (PA/PA) Word None English
HCF-11016A F-11016A Prior Authorization Physician Attachment (PA/PA) Completion Instructions (PDF, 22 KB) PDF None English
HCF-11018 F-11018 Prior Authorization Request Form (PA/RF) (PDF, 148 KB) PDF None English
HCF-11018 F-11018 Prior Authorization Request Form (PA/RF) Word None English
HCF-11019 F-11019 Prior Authorization / Physician Otological Report (PA/POR) (PDF, 67 KB) PDF None English
HCF-11019 F-11019 Prior Authorization / Physician Otological Report (PA/POR) Word None English
HCF-11019A F-11019A Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions (PDF, 49 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-11021 F-11021 Prior Authorization Request / Hearing Instrument and Audiological Services (PDF, 154 KB) PDF None English
HCF-11021 F-11021 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS2) Word None English
HCF-11021A F-11021A Prior Authorization Request / Hearing Instrument and Audiological Services Completion Instructions (PDF, 39 KB) PDF None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data (PDF, 54 KB) PDF None English
HCF-11022 F-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data Word 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, 27 KB) PDF None English
HCF-11025 F-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary (PDF, 37 KB) Encounters Submitted to Medicaid HMOs (PDF, 37 KB) 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 (PDF, 20 KB) Encounters Submitted to Medicaid HMOs Instructions (PDF, 20 KB) PDF None English
HCF-11026 F-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs (PDF, 30 KB) 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, 25 KB) 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, 32 KB) PDF None English
HCF-11029 F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) (PDF, 52 KB) PDF None English
HCF-11029 F-11029 Prior Authorization / Chiropractic Attachment (PA/CA) Word None English
HCF-11029A F-11029A Prior Authorization / Chiropractic Attachment (PA/CA) Completion Instructions (PDF, 43 KB) PDF None English
HCF-11030 F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) (PDF, 67 KB) PDF None English
HCF-11030 F-11030 Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Word None English
HCF-11030A F-11030A Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Completion Instructions (PDF, 40 KB) PDF None English
HCF-11031 F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) (PDF, 47 KB) PDF None English
HCF-11031 F-11031 Prior Authorization / Psychotherapy Attachment (PA/PSYA) Word None English
HCF-11031A F-11031A Prior Authorization / Psychotherapy Attachment (PA / PSYA) Completion Instructions (PDF, 39 KB) PDF None English
HCF-11032 F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) (PDF, 129 KB) PDF None English
HCF-11032 F-11032 Prior Authorization / Substance Abuse Attachment (PA/SAA) Word None English
HCF-11032A F-11032A Prior Authorization / Substance Abuse Attachment (PA/SAA) Instructions (PDF, 64 KB) PDF None English
HCF-11033 F-11033 Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) (PDF, 38 KB) PDF None English
HCF-11033 F-11033 Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Word None English
HCF-11033A F-11033A Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) Completion Instructions (PDF, 49 KB) PDF None English
HCF-11034 F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) (PDF, 73 KB) PDF None English
HCF-11034 F-11034 Prior Authorization / "J" Code Attachment (PA/JCA) Word None English
HCF-11034A F-11034A Prior Authorization / "J" Code Attachment (PA/JCA) Completion Instructions (PDF, 42 KB) PDF None English
HCF-11035 F-11035 Prior Authorization Dental Request (PA / DRF) (PDF, 64 KB) PDF None English
HCF-11035 F-11035 Prior Authorization Dental Request Form Word None English
HCF-11035A F-11035A Prior Authorization Dental Request Form [PA / DRF] Completion Instructions (PDF, 64 KB) PDF None English
HCF-11036 F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) (PDF, 104 KB) PDF None English
HCF-11036 F-11036 Prior Authorization / In-Home Treatment Attachment (PA / ITA) Word None English
HCF-11036A F-11036A Prior Authorization / In-Home Treatment Attachment (PA/ITA) Completion Instructions (PDF, 56 KB) PDF None English
HCF-11037 F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) (PDF, 81 KB) PDF None English
HCF-11037 F-11037 Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Word None English
HCF-11037A F-11037A Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) Instructions (PDF, 60 KB) PDF None English
HCF-11038 F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) (PDF, 80 KB) PDF None English
HCF-11038 F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Word None English
HCF-11038A F-11038A Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) Instructions (PDF, 47 KB) PDF None English
HCF-11039 F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) (PDF, 1354 KB) PDF None English
HCF-11039 F-11039 Prior Authorization / Spell of Illness Attachment (PA/SOIA) Word None English
HCF-11039A F-11039A Prior Authorization / Spell of Illness Attachment (PA/SOIA) Completion Instructions (PDF, 54 KB) PDF None English
HCF-11040 F-11040 Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) (PDF, 103 KB) PDF None English
HCF-11040 F-11040 Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Word None English
HCF-11040A F-11040A Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) Completion Instructions (PDF, 100 KB) PDF None English
HCF-11041 F-11041 Private Duty Nursing Prior Authorization Acknowledgment (PDF, 91 KB) PDF None English
HCF-11041 F-11041 Private Duty Nursing Prior Authorization Acknowledgment Word None English
HCF-11042 F-11042 Prior Authorization Amendment Request (PDF, 65 KB) PDF None English
HCF-11042 F-11042 Prior Authorization Amendment Request Word None English
HCF-11042A F-11042A Prior Authorization Amendment Request Completion Instructions (PDF, 27 KB) PDF None English
HCF-11044 F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) (PDF, 68 KB) PDF None English
HCF-11044 F-11044 Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Word None English
HCF-11044A F-11044A Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) Completion Instructions (PDF, 68 KB) PDF None English
HCF-11047 F-11047 Wisconsin Medicaid - Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 (PDF, 24 KB) 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, 29 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-11051 F-11051 Prior Authorization / Vision Services Attachment (PA/VA) (PDF, 85 KB) PDF None English
HCF-11051 F-11051 Prior Authorization / Vision Services Attachment (PA/VA) Word None English
HCF-11051A F-11051A Prior Authorization / Vision Services Attachment (PA/VA) Completion Instructions (PDF, 39 KB) PDF None English
HCF-11052 F-11052 STAT-PA Orthopedic Shoes Worksheet (PDF, 144 KB) PDF None English
HCF-11052 F-11052 STAT-PA Orthopedic Shoes Worksheet Word None English
HCF-11052A F-11052A STAT-PA Orthopedic Shoes Worksheet Completion Instructions (PDF, 98 KB) PDF None English
HCF-11054 F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) (PDF, 626 KB) PDF None English
HCF-11054 F-11054 Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Word None English
HCF-11054A F-11054A Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) Completion Instructions (PDF, 55 KB) PDF None English
HCF-11055 F-11055 STAT-PA System Instructions (PDF, 28 KB) PDF None English
HCF-11062 F-11062 Prior Authorization / Environmental Lead Inspection (PDF, 104 KB) PDF None English
HCF-11062 F-11062 Prior Authorization / Environmental Lead Inspection Word None English
HCF-11062A F-11062A Prior Authorization / Environmental Lead Inspection Instructions for Paper Prior Authorization or STAT-PA (PDF, 63 KB) PDF None English
HCF-11066 F-11066 Prior Authorization / Oxygen Attachment (PA/OA) (PDF, 173 KB) PDF None English
HCF-11066 F-11066 Prior Authorization / Oxygen Attachment (PA/OA) Word None English
HCF-11066A F-11066A Prior Authorization / Oxygen Attachment (PA/OA) Completion Instructions (PDF, 51 KB) PDF None English
HCF-11067 F-11067 Record of Actual Daily Oxygen Use (PDF, 127 KB) PDF None English
HCF-11067 F-11067 Record of Actual Daily Oxygen Use Word None English
HCF-11067A F-11067A Record of Actual Daily Oxygen Use Completion Instructions (PDF, 28 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-11076 F-11076 Prior Authorization Request (PA / RF) Completion Instructions for Residential Care Center Treatment Services (PDF, 36 KB) PDF None English
HCF-11076A F-11076A Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for initial admission and unplanned readmission within 90 days of discharge from RCC (PDF, 105 KB) PDF None English
HCF-11076A F-11076A 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 Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services (PDF, 86 KB) PDF None English
HCF-11076B F-11076B Prior Authorization / Residential Care Center Treatment Services Attachment (PA / RCCA) for continuing services Word None English
HCF-11076C F-11076C Prior Authorization / Residential Care Center Treatment Attachment (PA / RCCA) Completion Instructions for Initial Admissions, Unplanned Readmissions, and for Continuing Services (PDF, 34 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-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, 36 KB) 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, 35 KB) PDF None English
HCF-11080CA 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, 35 KB) PDF None English
HCF-11080CP 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 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-11088 F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) (PDF, 41 KB) PDF None English
HCF-11088 F-11088 Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Word None English
HCF-11088A F-11088A Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) Completion Instructions (PDF, 37 KB) PDF None English
HCF-11090 F-11090 Mental Health Day Treatment Functional Assessment (PDF, 169 KB) PDF None English
HCF-11090 F-11090 Mental Health Day Treatment Functional Assessment Word None English
HCF-11090A F-11090A Mental Health Day Treatment Functional Assessment Completion Instructions (PDF, 47 KB) PDF None English
HCF-11092 F-11092 Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs (PDF, 631 KB) PDF None English
HCF-11092 F-11092 Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Word None English
HCF-11092A F-11092A Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs Completion Instructions (PDF, 73 KB) PDF None English
HCF-11096 F-11096 Prior Authorization / Care Plan Attachment (PDF, 69 KB) PDF None English
HCF-11096 F-11096 Prior Authorization / Care Plan Attachment Word None English
HCF-11096A F-11096A Prior Authorization / Care Plan Attachment Completion Instructions (PDF, 68 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-11103 F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (PDF, 154 KB) PDF None English
HCF-11103 F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Word None English
HCF-11103A F-11103A Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan Completion Instructions (PDF, 36 KB) PDF None English
HCF-11129A F-11129A Wisconsin Medicaid - Federally Qualified Health Center Cost Report Completion Instructions (PDF, 102 KB) 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, 47 KB) PDF None English
HCF-11133 F-11133 Personal Care Screening Tool (PCST) (PDF, 91 KB) PDF None English
HCF-11133 F-11133 Personal Care Screening Tool (PCST) Word None English
HCF-11133A F-11133A Personal Care Screening Tool (PCST) Completion Instructions (PDF, 163 KB) PDF None English
HCF-11134 F-11134 Personal Care Prior Authorization Provider Acknowledgement (PDF, 46 KB) PDF None English
HCF-11134 F-11134 Personal Care Prior Authorization Provider Acknowledgement Word None English
HCF-11136 F-11136 Personal Care Addendum (PDF, 215 KB) PDF None English
HCF-11136 F-11136 Personal Care Addendum Word None English
HCF-11136A F-11136A Personal Care Addendum Completion Instructions (PDF, 47 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-11237 F-11237 Wisconsin Medicaid - Specialized Medical Vehicle Provider Affidavit (PDF, 69 KB) PDF None English
HCF-11237 F-11237 Wisconsin Medicaid - Specialized Medical Vehicle Provider Affidavit Word None English
HCF-11240 F-11240 Wisconsin Medicaid - Case Management Provider Information (PDF, 63 KB) PDF None English
HCF-11240 F-11240 Wisconsin Medicaid - Case Management Provider Information Word None English
HCF-11245 F-11245 Wisconsin Medicaid - Family Planning Clinics or Agencies (PDF, 52 KB) PDF None English
HCF-11245 F-11245 Wisconsin Medicaid - Family Planning Clinics or Agencies Word None English
HCF-11247 F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) (PDF, 41 KB) PDF None English
HCF-11247 F-11247 Wisconsin Medicaid - Services that can be billed under the Federally Qualified Health Center Clinic Number (Chart 1) Word None English
HCF-11248 F-11248 Wisconsin Medicaid - Services that cannot be billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2) (PDF, 52 KB) PDF None English
HCF-11248 F-11248 Wisconsin Medicaid - Services that cannot be billed under the Federally Qualified Health Center Assigned Clinic Number (Chart 2) Word None English
HCF-11252 F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum(PDF, 46 KB) PDF None English
HCF-11252 F-11252 Wisconsin Medicaid Private Duty Nursing for Members for Ventilator-Dependent Life-Support Addendum Word None English
HCF-11260 F-11260 Wisconsin Medicaid - Degree Addendum (PDF, 24 KB) PDF None English
HCF-11260 F-11260 Wisconsin Medicaid - Degree Addendum Word None English
HCF-11268 F-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification (PDF, 83 KB) PDF None English
HCF-11271 F-11271 Wisconsin Medicaid - Personal Care Provider Addendum (PDF, 22 KB) PDF None English
HCF-11271 F-11271 Wisconsin Medicaid - Personal Care Provider Addendum Word None English
HCF-11278 F-11278 Wisconsin Medicaid - PreNatal Care Coordination Outreach and Management Plan (PDF, 55 KB) PDF None English
HCF-11278 F-11278 Wisconsin Medicaid - PreNatal Care Coordination Outreach and Management Plan Word None English
HCF-11285 F-11285 Wisconsin Medicaid - HealthCheck Screener Affirmation (PDF, 32 KB) PDF None English
HCF-11285 F-11285 Wisconsin Medicaid - HealthCheck Screener Affirmation Word None English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan (PDF, 29 KB) PDF None English
HCF-11289 F-11289 Wisconsin Medicaid HealthCheck County Outreach Case Management Plan Word None English
HCF-11296 F-11296 Wisconsin Medicaid - SMV Transportation Service Informational (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 (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-11309 F-11309 BadgerCare Plus Express Enrollment for Children Provider Certification (PDF, 93 KB) PDF None English
HCF-11317 F-11317 Enrollment Criteria for Providers Express Enrollment of Pregnant Women, Children, and Individuals Requiring Family Planning-Only Services in BadgerCare Plus (PDF, 45 KB) PDF None English
HCF-11318 F-11318 Enrollment Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus (PDF, 38 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-13509 F-13509 Wisconsin Well Woman Program Provider Certification (PDF, 388 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, 121 KB) PDF None Arabic
HCF-16006H F-16006H FoodShare Wisconsin Change Report - Hmong (PDF, 141 KB) PDF None Hmong
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
HCF-16019AH F-16019AH FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 238 KB) PDF None Hmong
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, 70 KB) Paper Form Center English
  F-16066AR FoodShare Wisconsin Income Change Report - Arabic (PDF, 146 KB) PDF None Arabic
HCF-16066H F-16066H FoodShare Wisconsin Income Change Report - Hmong (PDF, 138 KB) PDF None Hmong
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