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) DMS
F-00100 State Vital Records Cover Letter DMS
F-00101 Authorization to Request Birth Records DMS
F-00107 Self-Employment Income Report DMS
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) DMS
F-00194 Prior Authorization / Preferred Drug List (PA/PDL) for Antiemetics Cannarinoids DMS
F-00219 Self-Employment Income Report - Farmer DMS
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB) DMS
F-00233 Renewal Summary Letter DMS
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information (PDF, 41 KB) DMS
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections DMS
F-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-00685 Statement of Tribal Affiliation (PDF, 24 KB) DMS
F-00704 Prior Authorization - Committee Public Testimony Registration (PDF, 497 KB) DMS
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS
F-00855 Medication Therapy Management Case Management Software Requirements (PDF, 591 KB) DMS
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF, 47 KB) DMS
F-00922 Behavioral Health Integrated Care Health Home Certification Application DMS
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-01112 HealthCheck Verification Card DMS
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-01359 Historical Earnings Verification Request DMS
F-01915 Gap Filling Eligibility Determinations Supplemental Letter DMS
F-01983 Self-Employment Income Worksheet: Business Capital Gains or Losses (Form 4797) DMS
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ) DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E) DMS
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F) DMS
F-10081 BadgerCare Plus Express Enrollment for Pregnant Women Application DMS
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DMS
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF, 54 KB) DMS
F-10110 Medicaid / BadgerCare Plus Certification DMS
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS
F-10115 BadgerCare Plus / Medicaid Health Insurance Information DMS
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative DMS
F-10129 Medicaid / BadgerCare Plus and Family Planning Waiver Registration Application DMS
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application (PDF, 654 KB) DMS
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-10141 Wisconsin Funeral and Cemetery Aids Program Application (PDF, 118 KB) DMS
F-10144 Life Insurance Inquiry DMS
F-10146 Employer Verification of Earnings DMS
F-10150 Your Rights and Responsibilities for Health Care / FoodShare DMS
F-10150A Your Rights and Responsibilities for Health Care DMS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF, 129 KB) DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-10161 Statement of Citizenship and/or Identity for Special Populations (PDF, 116 KB) DMS
F-10162 Verification of Veterans Benefits (PDF, 53 KB) DMS
F-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding (PDF, 24 KB) DMS
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) DMS

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Last Revised: December 18, 2014