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 Numbersort descending Title Division Other Location
F-00098 Summary of Information Letter (PDF, 224 KB) DHCAA
F-00100 State Vital Records Cover Letter DHCAA
F-00101 Authorization to Request Birth Records DHCAA
F-00107 Self-Employment Income Report DHCAA
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) DHCAA
F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids DHCAA
F-00219 Self-Employment Income Report - Farmer DHCAA
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) DHCAA
F-00233 Renewal Summary Letter DHCAA
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) DHCAA
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections DHCAA
F-00628 Consortium Response to the State IM Second Party Review Finding DHCAA
F-00685 Statement of Tribal Affiliation (PDF, 24 KB) DHCAA
F-00704 Prior Authorization - Committee Public Testimony Registration (PDF, 497 KB) DHCAA
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DHCAA
F-00855 Medication Therapy Management Case Management Software Requirements (PDF, 591 KB) DHCAA
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF, 47 KB) DHCAA
F-00922 Behavioral Health Integrated Care Health Home Certification Application DHCAA
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DHCAA
F-01112 HealthCheck Verification Card DHCAA
F-01160 Acknowledgement of Receipt of Hysterectomy Information DHCAA
F-01359 Historical Earnings Verification Request DHCAA
F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application DHCAA
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DHCAA
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) DHCAA
F-10110 Medicaid / BadgerCare Plus Certification DHCAA
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DHCAA
F-10115 BadgerCare Plus / Medicaid Health Insurance Information DHCAA
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative DHCAA
F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application DHCAA
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) DHCAA
F-10139 BadgerCare Plus Premium Information / Payment DHCAA
F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request (PDF, 88 KB) DHCAA
F-10144 Life Insurance Inquiry DHCAA
F-10146 Employer Verification of Earnings DHCAA
F-10150 Your Rights and Responsibilities for Health Care / FoodShare DHCAA
F-10150A Your Rights and Responsibilities for Health Care DHCAA
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) DHCAA
F-10154 Statement of Identity for Children Under 18 Years of Age DHCAA
F-10161 Statement of Citizenship and/or Identity for Special Populations (PDF, 116 KB) DHCAA
F-10162 Verification of Veterans Benefits (PDF, 53 KB) DHCAA
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) DHCAA
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding (PDF, 24 KB) OIG
F-10175 Statement of Identity for Persons in Institutional Care Facilities (PDF, 36 KB) DHCAA
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF, 376 KB) DHCAA
F-10182 BadgerCare Plus Application Packet DHCAA
F-10183 Information Change Report DHCAA
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) DHCAA
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DHCAA
F-11042 Prior Authorization Amendment Request OIG

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Last Revised: December 18, 2014