SeniorCare 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-00985 How the Affordable Care Act may affect SeniorCare members who get Prescriptions (PDF, 62 KB) DHCAA
F-10076 SeniorCare Application DHCAA
F-10080 SeniorCare Authorization of Representative (PDF, 486 KB) DHCAA
F-13161 Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure (PDF, 178 KB) DHCAA
F-13162 Wisconsin SeniorCare HIPAA Privacy Access Request (PDF, 183 KB) DHCAA
F-13163 Wisconsin SeniorCare HIPAA Privacy Accounting Request (PDF, 152 KB) DHCAA
F-13164 Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request (PDF, 163 KB) DHCAA
F-13165 Wisconsin SeniorCare HIPAA Privacy Amendment Request (PDF, 154 KB) DHCAA
F-13166 Wisconsin SeniorCare HIPAA Privacy Complaint (PDF, 157 KB) DHCAA
F-13167 Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization (PDF, 171 KB) DHCAA
F-13168 Wisconsin SeniorCare HIPAA Privacy Restriction Request (PDF, 155 KB) DHCAA
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) DHCAA
Last Revised: December 23, 2014