Medicaid 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-00010 Risk Agreement - Participant DLTC
F-00067 PROAct - Program Review Outcome / Activity Person-Centered Field Review Report DLTC
F-00076 Variance Request - Wait List DLTC
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-00154 Wisconsin Consultative Examination Inquiry 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-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections DHCAA
F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB) DHCAA
F-00407 Financial Records Request (PDF, 28 KB) 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-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers 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-01567 Long-Term Care Insurance Policy – Assignment of Benefits DHCAA
F-01596 Incident Report for CIP 1A/1B, CIP II, and COP-W Medicaid Waiver Programs DLTC
F-01661 Letter – Foster Care Termination DHCAA
F-10075 Wisconsin Well Woman Medicaid Determination (PDF, 78 KB) DHCAA
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DHCAA
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DHCAA
F-10096 Community Spouse Asset Share Notice DHCAA
F-10097 Medicaid Income Allocation Notice DHCAA
F-10098 Medicaid Member Asset Allocation Notice DHCAA
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB) DHCAA
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DHCAA
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice DHCAA
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice DHCAA
F-10108 Medicaid Manual Notice for Cost of Care Contribution 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-10112 Medicaid Disability Application DHCAA
F-10114 Medicaid Disability Redetermination Report (PDF, 222 KB) DHCAA
F-10115 BadgerCare Plus / Medicaid Health Insurance Information DHCAA
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration (PDF, 29 KB) DHCAA


Last Revised: December 23, 2014