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 Other Location
F-00010 Risk Agreement - Participant
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report
F-00076 Variance Request - Wait List
F-00098 Summary of Information Letter (PDF, 224 KB)
F-00100 State Vital Records Cover Letter
F-00101 Authorization to Request Birth Records
F-00107 Self-Employment Income Report
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB)
F-00154 Wisconsin Consultative Examination Inquiry
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals
F-00194 Prior Authorization/Preferred Drug List (PA/PDL) for Antiemetics, Cannabinoids
F-00219 Self-Employment Income Report - Farmer
F-00219W Self-Employment Income Report - Farmer Worksheet (PDF, 32 KB)
F-00233 Renewal Summary Letter
F-00286 Attestation to Administer Alpha Hydroxyprogesterone Caproate (17P) Compound Injections and Makena Injections
F-00332 Medicaid Purchase Plan Premium Information / Payment (PDF, 50 KB)
F-00407 Financial Records Request (PDF, 28 KB)
F-00628 Consortium Response to the State IM Second Party Review Finding
F-00685 Statement of Tribal Affiliation (PDF, 24 KB)
F-00704 Prior Authorization - Committee Public Testimony Registration (PDF, 497 KB)
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program
F-00855 Medication Therapy Management Case Management Software Requirements (PDF, 591 KB)
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF, 47 KB)
F-00922 Behavioral Health Integrated Care Health Home Certification Application
F-01018 Wisconsin Medicaid - Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age)
F-01112 HealthCheck Verification Card
F-01160 Acknowledgement of Receipt of Hysterectomy Information
F-01359 Historical Earnings Verification Request
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits
F-01596 Incident Report for CIP 1A/1B, CIP II, and COP-W Medicaid Waiver Programs
F-01661 Letter – Foster Care Termination
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter
F-01983 Self-Employment Income Worksheet: Business Capital Gains or Losses (Form 4797)
F-01984 Self-Employment Income Worksheet: Sole Proprietorship (Schedule C or Schedule C-EZ)
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D)
F-01986 Self-Employment Income Worksheet: Sole Proprietorship (Schedule E)
F-01987 Self-Employment Income Worksheet: Sole Proprietorship (Schedule F)
F-02059 New Carrier Insurance Disclosure Onboarding (PDF, 750 KB)
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding (PDF, 132 KB)
F-02231 Program Integrity Annual Survey – Family Care Managed Care Organizations (MCOs)
F-10075 Wisconsin Well Woman Medicaid Determination (PDF, 78 KB)
F-10093 Medicaid and BadgerCare Plus Overpayment Notice
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse
F-10096 Community Spouse Asset Share Notice
F-10097 Medicaid Income Allocation Notice
F-10098 Medicaid Member Asset Allocation Notice
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility (PDF, 312 KB)
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet


Last Revised: December 23, 2014