BadgerCare Plus Forms

Clicking the Assigned Number link will either download the selected form (if only one version is available) OR it will open a page that will display all language versions of that form. From that page you can choose and download the needed forms.
Assigned Number Title Division Other Location
F-10183 Information Change Report DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-10182 BadgerCare Plus Application Packet DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application DMS
F-00107 Self-Employment Income Report DMS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-11042 Prior Authorization Amendment Request DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-10146 Employer Verification of Earnings DMS
F-01359 Historical Earnings Verification Request DMS
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) DMS
F-00233 Renewal Summary Letter DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-10150A Your Rights and Responsibilities for Health Care DMS
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids DMS
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-00685 Statement of Tribal Affiliation DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS
F-00098 Summary of Information Letter DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-00101 Authorization to Request Birth Records DMS
F-10081 BadgerCare Plus – Express Enrollment for Pregnant Women Application DMS
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS
F-10161 Statement of Citizenship and/or Identity DMS
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application DMS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS
F-16014 Notice of Program Violation DMS
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-16104 Local Agency Customer Feedback DMS
F-16022 Social Security Number Referral DMS
F-13025 BadgerCare Plus Premium Employer Wage Withholding and Instructions DMS
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer and Instructions DMS
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-10141 Wisconsin Funeral and Cemetery Aids Program Application DMS
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS

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Last Revised: April 11, 2018