|
HCF-10075
|
F-10075
|
Wisconsin Well Woman Medicaid Determination (PDF, 85 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-10076
|
F-10076
|
SeniorCare Application (PDF, 179 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-10076A
|
F-10076A
|
SeniorCare Instructions for Application Form (PDF, 71 KB)
|
PDF
|
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, 44 KB)
|
PDF
|
None
|
English
|
|
HCF-10093
|
F-10093
|
Medicaid / BadgerCare Plus Overpayment Notice (PDF, 364 KB)
|
PDF
|
None
|
English
|
|
HCF-10093S
|
F-10093S
|
Medicaid / BadgerCare Overpayment Notice - Spanish (PDF, 31 KB)
|
PDF
|
None
|
Spanish
|
|
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, 37 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, 731 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-10101H
|
F-10101H
|
Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet - Hmong (PDF, 362)
|
PDF
|
None
|
Hmong
|
|
HCF-10101S
|
F-10101S
|
Wisconsin Medicaid for the Elderly, Blind or Disabled
Application Packet - Spanish(PDF, 324 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 Remaining Deductible Update (PDF, 131 KB)
|
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, 40 KB)
|
PDF
|
None
|
English
|
|
HCF-10111A
|
F-10111A
|
Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF, 18 KB)
|
PDF
|
None
|
English
|
|
HCF-10112
|
F-10112
|
Medicaid Disability Application (PDF, 1.9 MB)
|
PDF
|
Form Center
|
English
|
|
HCF-10112S
|
F-10112S
|
Medicaid Disability Application - Spanish (PDF, 186 KB)
|
PDF
|
None
|
Spanish
|
|
HCF-10114
|
F-10114
|
Medicaid Disability Redetermination Report (PDF, 877 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, 46 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, 192 KB)
|
PDF
|
None
|
English
|
|
HCF-10126H
|
F-10126H
|
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Hmong (PDF, 242 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-10126S
|
F-10126S
|
Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative - Spanish (PDF, 529 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, 46 KB)
|
PDF
|
None
|
English
|
|
HCF-10129H
|
F-10129H
|
Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application - Hmong (PDF, 32 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-10129S
|
F-10129S
|
Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application - Spanish (PDF, 33 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, 50 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-10137H
|
F-10137H
|
Medicaid Change Report - Hmong (PDF, 94 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-10137R
|
F-10137R
|
Medicaid Change Report - Russian (PDF, 246 KB)
|
PDF
|
None
|
Russian
|
|
HCF-10137S
|
F-10137S
|
Medicaid Change Report - Spanish (PDF, 88 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, 86 KB)
|
PDF
|
None
|
English
|
|
HCF-10140S
|
F-10140S
|
Wisconsin Medicaid Supplement to FoodShare Wisconsin Application - Spanish (PDF, 90 KB)
|
PDF
|
None
|
Spanish
|
|
HCF-10141
|
F-10141
|
Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 84 KB)
|
PDF
|
None
|
English
|
|
HCF-10141A
|
F-10141A
|
Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions (PDF, 20 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, 41 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-10148
|
F-10148
|
Application to become a Certified Partner / Provider for BadgerCare Plus Express Enrollment for Children (PDF, 120 KB)
|
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 Health Care / FoodShare (PDF, 79 KB)
|
PDF
|
None
|
English
|
|
DHCAA
|
F-10150A
|
Your Rights and Responsibilities for Health Care (PDF, 56 KB)
|
PDF
|
None
|
English
|
|
DHCAA
|
F-10150B
|
Your Rights and Responsibilities for FoodShare (PDF, 103 KB)
|
PDF
|
None
|
English
|
|
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, 136 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, 102 KB)
|
PDF
|
None
|
English
|
|
HCF-10176
|
F-10176
|
BadgerCare Plus Express Enrollment Change Request for Partners / Providers (PDF, 96 KB)
|
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, 132 KB)
|
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, 376 KB)
|
PDF
|
None
|
English
|
|
HCF-10182
|
F-10182
|
BadgerCare Plus Application Packet (PDF, 878 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-10182H
|
F-10182H
|
BadgerCare Plus Application Packet - Hmong (PDF, 1.7 MB)
|
PDF
|
None
|
Hmong
|
|
HCF-10182S
|
F-10182S
|
BadgerCare Plus Application Packet - Spanish (PDF, 819 KB)
|
PDF
|
None
|
Spanish
|
|
HCF-10183
|
F-10183
|
BadgerCare Plus Change Report (PDF, 299 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-10183H
|
F-10183H
|
BadgerCare Plus Change Report - Hmong (PDF, 307 KB)
|
PDF
|
Form Center
|
Hmong
|
|
HCF-10183S
|
F-10183S
|
BadgerCare Plus Change Report - Spanish (PDF, 307 KB)
|
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, 110 KB)
|
PDF
|
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-11001
|
F-11001
|
Wisconsin Medicaid Out-of-State Provider Data Sheet (PDF, 94 KB)
|
PDF
|
None
|
English
|
|
HCF-11001
|
F-11001
|
Wisconsin Medicaid Out-of-State Provider Data Sheet
|
Word
|
None
|
English
|
|
HCF-11001A
|
F-11001A
|
Wisconsin Medicaid Out-of-State Provider Data Sheet Completion Instructions (PDF, 53 KB)
|
PDF
|
None
|
English
|
|
HCF-11002
|
F-11002
|
Wisconsin Medicaid In-State Emergency Provider Data Sheet (PDF, 80 KB)
|
PDF
|
None
|
English
|
|
HCF-11002
|
F-11002
|
Wisconsin Medicaid In-State Emergency Provider Data Sheet
|
Word
|
None
|
English
|
|
HCF-11002A
|
F-11002A
|
Wisconsin Medicaid In-State Emergency Provider Data Sheet Completion Instructions (PDF, 46 KB)
|
PDF
|
None
|
English
|
|
HCF-11008
|
F-11008
|
ForwardHealth Prior Authorization / Therapy Attachment (PA/TA) (PDF, 83 KB)
|
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, 98 KB)
|
PDF
|
None
|
English
|
|
HCF-11010
|
F-11010
|
ForwardHealth Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format (PDF, 253 KB)
|
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, 31 KB)
|
PDF
|
None
|
English
|
|
HCF-11011
|
F-11011
|
ForwardHealth Prior Authorization / Birth to 3 Attachment (PA/B3) (PDF, 48 KB)
|
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, 80 KB)
|
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, 44 KB)
|
PDF
|
None
|
English
|
|
HCF-11014
|
F-11014
|
ForwardHealth Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services (PDF, 67 KB)
|
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, 50 KB)
|
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, 22 KB)
|
PDF
|
None
|
English
|
|
HCF-11018
|
F-11018
|
ForwardHealth Prior Authorization Request Form (PA/RF) (PDF, 148 KB)
|
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, 67 KB)
|
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, 49 KB)
|
PDF
|
None
|
English
|
|
HCF-11020
|
F-11020
|
ForwardHealth Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) (PDF, 122 KB)
|
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, 54 KB)
|
PDF
|
None
|
English
|
|
HCF-11021
|
F-11021
|
ForwardHealth Prior Authorization Request / Hearing Instrument and Audiological Services (PDF, 154 KB)
|
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, 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, 20 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, 15 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, 19 KB)
|
PDF
|
None
|
English
|
|
HCF-11029
|
F-11029
|
ForwardHealth Prior Authorization / Chiropractic Attachment (PA/CA) (PDF, 52 KB)
|
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, 43 KB)
|
PDF
|
None
|
English
|
|
HCF-11030
|
F-11030
|
ForwardHealth Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) (PDF, 67 KB)
|
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, 40 KB)
|
PDF
|
None
|
English
|
|
HCF-11031
|
F-11031
|
ForwardHealth Prior Authorization / Psychotherapy Attachment (PA/PSYA) (PDF, 47 KB)
|
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, 39 KB)
|
PDF
|
None
|
English
|
|
HCF-11032
|
F-11032
|
ForwardHealth Prior Authorization / Substance Abuse Attachment (PA/SAA) (PDF, 129 KB)
|
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, 64 KB)
|
PDF
|
None
|
English
|
|
HCF-11033
|
F-11033
|
ForwardHealth Prior Authorization / Mental Health and/Or Substance Abuse Evaluation Attachment (PA / EA) (PDF, 38 KB)
|
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, 49 KB)
|
PDF
|
None
|
English
|
|
HCF-11034
|
F-11034
|
ForwardHealth Prior Authorization / "J" Code Attachment (PA/JCA) (PDF, 73 KB)
|
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, 42 KB)
|
PDF
|
None
|
English
|
|
HCF-11035
|
F-11035
|
ForwardHealth Prior Authorization Dental Request (PA / DRF) (PDF, 64 KB)
|
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, 64 KB)
|
PDF
|
None
|
English
|
|
HCF-11036
|
F-11036
|
ForwardHealth Prior Authorization / In-Home Treatment Attachment (PA / ITA) (PDF, 104 KB)
|
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, 56 KB)
|
PDF
|
None
|
English
|
|
HCF-11037
|
F-11037
|
ForwardHealth Prior Authorization / Substance Abuse Day Treatment Attachment (PA/SADTA) (PDF, 81 KB)
|
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, 60 KB)
|
PDF
|
None
|
English
|
|
HCF-11038
|
F-11038
|
ForwardHealth Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) (PDF, 80 KB)
|
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, 47 KB)
|
PDF
|
None
|
English
|
|
HCF-11039
|
F-11039
|
ForwardHealth Prior Authorization / Spell of Illness Attachment (PA/SOIA) (PDF, 76 KB)
|
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, 51 KB)
|
PDF
|
None
|
English
|
|
HCF-11040
|
F-11040
|
ForwardHealth Prior Authorization / Child Adolescent Day Treatment Attachment (PA/CADTA) (PDF, 103 KB)
|
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, 100 KB)
|
PDF
|
None
|
English
|
|
HCF-11041
|
F-11041
|
ForwardHealth Private Duty Nursing Prior Authorization Acknowledgment (PDF, 91 KB)
|
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, 65 KB)
|
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, 27 KB)
|
PDF
|
None
|
English
|
|
HCF-11044
|
F-11044
|
ForwardHealth Prior Authorization / Home Health Therapy / Attachment (PA/HHTA) (PDF, 68 KB)
|
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, 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
|
ForwardHealth Prior Authorization / Drug Attachment (PA/DGA) (PDF, 82 KB)
|
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, 44 KB)
|
PDF
|
None
|
English
|
|
HCF-11051
|
F-11051
|
ForwardHealth Prior Authorization / Vision Services Attachment (PA/VA) (PDF, 85 KB)
|
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, 39 KB)
|
PDF
|
None
|
English
|
|
HCF-11052
|
F-11052
|
ForwardHealth STAT-PA Orthopedic Shoes Worksheet (PDF, 144 KB)
|
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, 98 KB)
|
PDF
|
None
|
English
|
|
HCF-11054
|
F-11054
|
ForwardHealth Prior Authorization / Enteral Nutrition Product Attachment (PA/ENPA) (PDF, 626 KB)
|
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, 55 KB)
|
PDF
|
None
|
English
|
|
HCF-11055
|
F-11055
|
ForwardHealth STAT-PA System Instructions (PDF, 28 KB)
|
PDF
|
None
|
English
|
|
HCF-11056
|
F-11056
|
ForwardHealth Prior Authorization Drug Attachment for Alpha-1 Proteinase Inhibitors (PDF, 65 KB)
|
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, 67 KB)
|
PDF
|
None
|
English
|
|
HCF-11062
|
F-11062
|
ForwardHealth Prior Authorization / Environmental Lead Inspection (PDF, 104 KB)
|
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, 63 KB)
|
PDF
|
None
|
English
|
|
HCF-11066
|
F-11066
|
ForwardHealth Prior Authorization / Oxygen Attachment (PA/OA) (PDF, 173 KB)
|
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, 51 KB)
|
PDF
|
None
|
English
|
|
HCF-11067
|
F-11067
|
ForwardHealth Record of Actual Daily Oxygen Use (PDF, 127 KB)
|
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, 28 KB)
|
PDF
|
None
|
English
|
|
HCF-11075
|
F-11075
|
ForwardHealth Prior Authorization / Preferred Drug List (PA PDL) Exemption Request (PDF, 42 KB)
|
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, 51 KB)
|
PDF
|
None
|
English
|
|
HCF-11076
|
F-11076
|
ForwardHealth Prior Authorization Request (PA / RF) Completion Instructions for Residential Care Center Treatment Services (PDF, 36 KB)
|
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, 105 KB)
|
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, 86 KB)
|
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, 34 KB)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 50 KB)
|
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 (for Dates of Service on and after January 1, 2013)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 43 KB)
|
PDF
|
None
|
English
|
|
HCF-11078
|
F-11078
|
ForwardHealth 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
|
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, 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, 24 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, 27 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, 23 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
|
ForwardHealth Prior Authorization / Brand Medically Necessary Attachment (PA/BMNA) (PDF, 65 KB)
|
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, 46 KB)
|
PDF
|
None
|
English
|
|
HCF-11088
|
F-11088
|
ForwardHealth Prior Authorization / Health and Behavior Intervention Attachment (PA/HBA) (PDF, 41 KB)
|
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, 37 KB)
|
PDF
|
None
|
English
|
|
HCF-11090
|
F-11090
|
ForwardHealth Mental Health Day Treatment Functional Assessment (PDF, 169 KB)
|
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, 47 KB)
|
PDF
|
None
|
English
|
|
HCF-11092
|
F-11092
|
ForwardHealth Wisconsin Medicaid Prior Authorization / Preferred Drug List (PA/PDL) for Growth Hormone Drugs (PDF, 65 KB)
|
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, 64 KB)
|
PDF
|
None
|
English
|
|
HCF-11096
|
F-11096
|
ForwardHealth Prior Authorization / Care Plan Attachment (for dates of service on or after May 1, 2010) (PDF, 69 KB)
|
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, 68 KB)
|
PDF
|
None
|
English
|
|
HCF-11097
|
F-11097
|
ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents (for Dates of Service on and after January 1, 2013) (PDF, 60 KB)
|
PDF
|
None
|
English
|
|
HCF-11097
|
F-11097
|
ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents (for Dates of Service on and after January 1, 2013)
|
Word
|
None
|
English
|
|
HCF-11097A
|
F-11097A
|
ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Stimulants and Related Agents Completion Instructions (for Dates of Service on and after January 1, 2013) (PDF, 60 KB)
|
PDF
|
None
|
English
|
|
HCF-11103
|
F-11103
|
ForwardHealth Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (PDF, 154 KB)
|
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, 36 KB)
|
PDF
|
None
|
English
|
|
HCF-11129A
|
F-11129A
|
Wisconsin Medicaid Federally Qualified Health Center Cost Report Completion Instructions (PDF, 53 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, 27 KB)
|
PDF
|
None
|
English
|
|
HCF-11133
|
F-11133
|
ForwardHealth Personal Care Screening Tool (PCST) (PDF, 91 KB)
|
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, 163 KB)
|
PDF
|
None
|
English
|
|
HCF-11134
|
F-11134
|
ForwardHealth Personal Care Prior Authorization Provider Acknowledgement (PDF, 46 KB)
|
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, 215 KB)
|
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, 47 KB)
|
PDF
|
None
|
English
|
|
HCF-11183
|
F-11183
|
ForwardHealth Pharmacy Services Lock-In Program Member (PDF, 25 KB)
Referral to Another Provider for Services
|
PDF
|
None
|
English
|
|
HCF-11183
|
F-11183
|
ForwardHealth 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, 41 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-11257
|
F-11257
|
Wisconsin Medicaid - Private Duty Nurse (PDN) Providers Addendum For Nurses in Independent Practice (PDF, 22 KB)
|
PDF
|
None
|
English
|
|
HCF-11257
|
F-11257
|
Wisconsin Medicaid - Private Duty Nurse (PDN) Providers Addendum For Nurses in Independent Practice
|
Word
|
None
|
English
|
|
HCF-11258
|
F-11258
|
Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Life-Support Adult (Age 17 and Over) (PDF, 534 KB)
|
PDF
|
None
|
English
|
|
HCF-11258
|
F-11258
|
Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Life-Support Adult (Age 17 and Over)
|
Word
|
None
|
English
|
|
HCF-11259
|
F-11259
|
Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Lifge-Support Pediatric (Ages 0-16) (PDF, 531 KB)
|
PDF
|
None
|
English
|
|
HCF-11259
|
F-11259
|
Wisconsin Medicaid - Declaration of Skill Acquisition - Private Duty Nursing for Members Ventilator Dependent for Lifge-Support Pediatric (Ages 0-16)
|
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, 100 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-11279
|
F-11279
|
Wisconsin Medicaid Memorandum of Understanding (Sample Format) between HMO and Prenatal Care Coordination Agency (PDF, 27 KB)
|
PDF
|
None
|
English
|
|
HCF-11279
|
F-11279
|
Wisconsin Medicaid Memorandum of Understanding (Sample Format) between HMO and Prenatal Care Coordination Agency
|
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, 46 KB)
|
PDF
|
None
|
English
|
|
HCF-11303
|
F-11303
|
ForwardHealth Prior Authorization / Preferred Drug List (PA/PDL) for Elidel and Protopic (PDF, 49 KB)
|
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, 54 KB)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 61 KB)
|
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 (for Dates of Service on and after January 1, 2013)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 55 KB)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 54 KB)
|
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 (for Dates of Service on and after January 1, 2013)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 52 KB)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 58 KB)
|
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 (for Dates of Service on and after January 1, 2013)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 52 KB)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 63 KB)
|
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 (for Dates of Service on and after January 1, 2013)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 53 KB)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 71 KB)
|
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 (for Dates of Service on and after January 1, 2013)
|
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 (for Dates of Service on and after January 1, 2013) (PDF, 54 KB)
|
PDF
|
None
|
English
|
|
HCF-11309
|
F-11309
|
BadgerCare Plus Express Enrollment for Children Provider Certification (PDF, 92 KB)
|
PDF
|
None
|
English
|
|
HCF-11317
|
F-11317
|
ForwardHealth Certification Criteria For Providers Express Enrollment of Pregnant Women in BadgerCare Plus (PDF, 42 KB)
|
PDF
|
None
|
English
|
|
HCF-11318
|
F-11318
|
ForwardHealth Certification Criteria For Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus (PDF, 42 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, 72 KB)
|
PDF
|
None
|
English
|
|
HCF-13026
|
F-13026
|
BadgerCare Plus Premium Member / Employer Electronic Funds Transfer (PDF, 91 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
|
ForwardHealth Adjustment / Reconsideration Request (PDF, 104 KB)
|
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, 49 KB)
|
PDF
|
None
|
English
|
|
HCF-13047
|
F-13047
|
ForwardHealth Timely Filing Appeals Request (PDF, 55 KB)
|
PDF
|
None
|
English
|
|
HCF-13047
|
F-13047
|
ForwardHealth Timely Filing Appeals Request
|
Word
|
None
|
English
|
|
HCF-13066
|
F-13066
|
Wisconsin Medicaid Claim Refund (PDF, 69 KB)
|
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, 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
|
ForwardHealth Pharmacy Special Handling Request (PDF, 58 KB)
|
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, 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
|
ForwardHealth Trading Partner 835 Designation (PDF, 58 KB)
|
PDF
|
None
|
English
|
|
HCF-13993
|
F-13393
|
ForwardHealth Trading Partner 835 Designation
|
Word
|
None
|
English
|
|
HCF-13393A
|
F-13393A
|
ForwardHealth Trading Partner 835 Designation Completion Instructions (PDF, 31 KB)
|
PDF
|
None
|
English
|
|
HCF-13470
|
F-13470
|
ForwardHealth Claim Form Attachment Cover Page (PDF, 100 KB)
|
PDF
|
None
|
English
|
|
HCF-13470
|
F-13470
|
ForwardHealth Claim Form Attachment Cover Page
|
Word
|
None
|
English
|
|
HCF-13470A
|
F-13470A
|
ForwardHealth Claim Forms Attachment Cover Page Completion Instructions (PDF, 18 KB)
|
PDF
|
None
|
English
|
|
HCF-13509
|
F-13509
|
Wisconsin Well Woman Program Provider Certification (PDF, 385 KB)
|
PDF
|
None
|
English
|
|
HCF-13622
|
F-13622
|
ForwardHealth InterChange Implementation Transitional Payment Request (PDF, 84 KB)
|
PDF
|
None
|
English
|
|
HCF-13622
|
F-13622
|
ForwardHealth InterChange Implementation Transitional Payment Request
|
Word
|
None
|
English
|
|
HCF-14014
|
F-14014
|
Authorization to Disclose Information to Disability Determination Bureau (DDB) (PDF, 50 KB)
|
PDF
|
None
|
English
|
|
HCF-14014AS
|
F-14014AS
|
Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) - Spanish (PDF, 86 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, 200 KB)
|
PDF
|
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, 110 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-16006H
|
F-16006H
|
FoodShare Wisconsin Change Report - Hmong (PDF, 68 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-16006S
|
F-16006S
|
FoodShare Wisconsin Change Report - Spanish (PDF, 116 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-16019A
|
F-16019A
|
FoodShare Wisconsin Registration / Important Information (PDF, 565 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-16019AH
|
F-16019AH
|
FoodShare Wisconsin Registration / Important Information - Hmong (PDF, 56 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-16019AS
|
F-16019AS
|
FoodShare Wisconsin Registration / Important Information - Spanish (PDF, 53 KB)
|
PDF
|
None
|
Spanish
|
|
HCF-16019B
|
F-16019B
|
FoodShare Wisconsin Application / Registration (PDF, 215 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-16019BH
|
F-16019BH
|
FoodShare Wisconsin Application / Registration - Hmong (PDF, 243 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-16019BS
|
F-16019BS
|
FoodShare Wisconsin Application / Registration - Spanish (PDF, 350 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, 582 KB)
|
PDF
|
None
|
English
|
|
HCF-16024S
|
F-16024S
|
Notice of Disqualification - Spanish (PDF, 867 KB)
|
PDF
|
None
|
Spanish
|
|
HCF-16025
|
F-16025
|
Disqualification Consent Agreement (PDF, 46 KB)
|
PDF
|
None
|
English
|
|
HCF-16025S
|
F-16025S
|
Disqualification Consent Agreement - Spanish (PDF, 31 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, 37 KB)
|
PDF
|
None
|
English
|
|
HCF-16035
|
F-16035
|
Self-Employment Income Worksheet - Subchapter S Corporation (PDF, 60 KB)
|
PDF
|
None
|
English
|
|
HCF-16036
|
F-16036
|
Self-Employment Income Worksheet - Partnership (PDF, 49 KB)
|
PDF
|
None
|
English
|
|
HCF-16037
|
F-16037
|
Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business (PDF, 72 KB)
|
PDF
|
None
|
English
|
|
HCF-16038
|
F-16038
|
Administrative Disqualification Hearing Notice (PDF, 81 KB)
|
PDF
|
None
|
English
|
|
HCF-16039
|
F-16039
|
Waiver of Administrative Disqualification Hearing (PDF, 61 KB)
|
PDF
|
None
|
English
|
|
HCF-16039S
|
F-16039S
|
Waiver of Administrative Disqualification Hearing - Spanish (PDF, 75 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, 67 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, 45 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-16066H
|
F-16066H
|
FoodShare Wisconsin Income Change Report - Hmong (PDF, 38 KB)
|
PDF
|
None
|
Hmong
|
|
HCF-16066S
|
F-16066S
|
FoodShare Wisconsin Income Change Report - Spanish (PDF, 37 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 Form 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, 17 KB)
|
PDF
|
Form Center
|
English
|
|
HCF-16104S
|
F-16104S
|
Local Agency Customer Feedback - Spanish (PDF, 16 KB)
|
PDF
|
Form Center
|
Spanish
|
|
HCF-9002
|
F-19002
|
Affidavit of Return or Exchange of Food Coupons (PDF, 615 KB)
|
PDF
|
None
|
English
|
