BadgerCare Plus Forms

Assigned Numbersort descending Title Division Other Location Language
F-00098 Summary of Information Letter (PDF, 224 KB) DHCAA English
F-00100 State Vital Records Cover Letter DHCAA English
F-00101 Authorization to Request Birth Records DHCAA English
F-00107 Self-Employment Income Report (PDF, 91 KB) DHCAA English
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) DHCAA English
F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids DHCAA English
F-00219 Self-Employment Income Report - Farmer DHCAA English
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) DHCAA English
F-00233 Renewal Summary Letter DHCAA English
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) DHCAA English
F-00628 Consortium Response to the State IM Second Party Review Finding DHCAA English
F-00685 Statement of Tribal Affiliation (PDF, 24 KB) DHCAA English
F-00704 Prior Authorization - Committee Public Testimony Registration (PDF, 29 KB) DHCAA English
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DHCAA English
F-00855 Medication Therapy Management Case Management Software Requirements (PDF, 591 KB) DHCAA English
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF, 47 KB) DHCAA English
F-00914 BadgerCare Plus Tax Filer Information (PDF, 238 KB) DHCAA English
F-00914A BadgerCare Plus Tax Filer Information More About Form F-00914 for Consortia Partners and Stake Holders (PDF, 51 KB) DHCAA English
F-00922 Behavioral Health Integrated Care Health Home Certification Application DHCAA English
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DHCAA English
F-01112 HealthCheck Verification Card DHCAA English
F-01160 Acknowledgement of Receipt of Hysterectomy Information DHCAA English
F-01359 Historical Earnings Verification Request DHCAA English
F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application DHCAA English
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DHCAA English
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) DHCAA English
F-10110 Medicaid / BadgerCare Plus Certification DHCAA English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification (PDF, 32 KB) DHCAA English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information (PDF, 61 KB) DHCAA English
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (PDF, 539 KB) DHCAA English

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Last Revised: December 18, 2014