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 Number Title Division Other Location
F-10187 Divestment Penalty and Undue Hardship Notice DMS
F-10112 Medicaid Disability Application DMS
F-10097 Medicaid Income Allocation Notice DMS
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-10112A Medicaid – Disability Application Addendum DMS
F-01316 Medicaid Purchase Plan (MAPP) Premium Calculation Worksheet DMS
F-01297 Medicaid Institution Determination Worksheet DMS
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-02577 Proof of In-Kind Hours DMS
F-16015 Notice of Approval of Benefits/Positive Change in Benefits DMS
F-00332 Medicaid Purchase Plan Premium Information / Payment DMS
F-10101 Wisconsin Medicaid for the Elderly, Blind or Disabled Application Packet DMS
F-02340 Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement DMS
F-10114 Medicaid Disability Redetermination Report DMS
F-16001 Notice of Denial of Benefits/Negative Change in Benefits DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-10137 Medicaid Change Report DMS
F-22541 Incident Report – IRIS DMS
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS
F-00194 Prior Authorization Drug Attachment for Antiemetics, Cannabinoids DMS
F-10146 Employer Verification of Earnings DMS
F-01359 Historical Earnings Verification Request DMS
F-11130B Community Health Center Interim Report DMS
F-01567 Long-Term Care Insurance Policy – Assignment of Benefits DMS
F-10162 Verification of Veterans Benefits DMS
F-00219 Self-Employment Income Report: Farm Business DMS
F-00107 Self-Employment Income Report DMS
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-20445 Individual Service Plan – Children’s Long-Term Support Programs DMS
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS
F-01160 Acknowledgement of Receipt of Hysterectomy Information DMS
F-11042 Prior Authorization Amendment Request DMS
F-10093 Wisconsin Medicaid and BadgerCare Plus Overpayment Notice DMS
F-00233 Renewal Summary Letter DMS
F-01985 Self-Employment Income Worksheet: Personal Capital Gains or Losses (Schedule D) DMS
F-10150A Your Rights and Responsibilities for Health Care DMS
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS
F-00180C Wisconsin Medicaid Program Provider Agreement and Acknowledgement of Terms of Participation for Waiver Service Provider Agencies or Individuals DMS
F-00067 Program Review Outcome / Activity Person-Centered Field Review Report DMS
F-16035 Self-Employment Income Worksheet: S Corporation (Schedule K-1 [Form 1120S] and Form 1120S) DMS
F-16036 Self-Employment Income Worksheet: Partnership (Schedule K-1 [Form 1065] and Form 1065) DMS
F-00628 Consortium Response to the State IM Second Party Review Finding DMS
F-00685 Statement of Tribal Affiliation DMS
F-00100 State Vital Records Birth Certificate Request Letter DMS
F-00101 Authorization to Request Birth Records DMS
F-00154 Wisconsin Consultative Examination Inquiry DMS

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Last Revised: April 11, 2018