Family Care 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-00009 Unprocessed Family Care, Pace, or Partnership Disenrollment Request (PDF, 281 KB) DHCAA
F-00046 Family Care Program - Enrollment DLTC
F-00152 MCO Notification To Pay Over The Medicaid Fee-For-Service Reimbursement Rate DLTC
F-00152A Fiscal Analysis Details for Pay Over the Medicaid Fee-for-Service Rate Request DLTC
F-00221 Family Care / IRIS Member Requested Disenrollment DPH
F-00221A Family Care / Partnership / PACE / IRIS - Disenrollment Routing DPH
F-00221B Family Care / Partnership / PACE / IRIS - Refusal to Accept Services and MCO Requested Disenrollment Routing DLTC
F-00232 Notice of Action - MCOs DLTC
F-00236 Request for a State Fair Hearing - MCO DLTC
F-00237 Appeal Request - MCOs DLTC
F-00295 Medical and Remedial Expenses Checklist - Update DLTC
F-00395 Family Care / Family Care Partnership Prevocational Services Six-Month Progress Report and Service Plan DLTC
F-01281 Letter - Notice to Current COP Participants-Model DLTC
F-01281A Letter - Notice to Current COP-W, CIP and Brain Injury Waiver Participants-Model DLTC
F-01282 Monthly Enrollment Discrepancy Report Template-Model DLTC
F-01283 Notification of Non-Covered Benefit Letter Template-Model DLTC
F-01286 Transition - Final Plan Template - Model DLTC
F-01287 Transition - Initial Plan Template-Model DLTC
F-01655 Enrollment Discrepancy Report DLTC
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DHCAA
F-13039 Estate Recovery Program (ERP) Disclosure DHCAA
Last Revised: December 23, 2014