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Medicaid Forms

Below is a list of all Medicaid forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-11040A Instructions DMS English 12/2019 PDF No
F-03112I Instructions for Logging HMO Appeals DMS English 01/2024 PDF No
F-00107 Instructions, Self-Employment Income Report DMS English 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107 Instructions, Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-01234A Instructions: Explanation of Medical Benefits DMS English 11/2023 PDF No
F-10110A Instructions: Medicaid/BadgerCare Plus Eligibility Certification DMS English 01/2018 HTML No
F-11133A Instructions: Personal Care Screening Tool (PCST) DMS English 08/2017 PDF No
F-11010A Instructions: Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS English 01/2018 PDF No
F-11008A Instructions: Prior Authorization / Therapy Attachment (PA/TA) DMS English 05/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Hmong DMS Hmong 06/2019 PDF No
F-00219 Instructions: Self-Employment Income Report: Farm Business, Spanish DMS Spanish 06/2019 PDF No
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS English 07/2008 PDF No
F-03102 Katie Beckett Disability Evaluation Form DMS English 11/2022 PDF No
F-03102 Katie Beckett Disability Evaluation Form DMS English 11/2022 Word No
F-01661 Letter - Foster Care Termination, Family DMS English 07/2023 Word No
F-01661A Letter - Foster Care Termination, Youth DMS English 11/2023 Word No
F-01567A Letter: Request for Assignment of Medical Benefits DMS English 01/2021 Word No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 PDF No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 Word No
F-01567S Long-Term Care Insurance Policy - Assignment of Benefits, Spanish DMS Spanish 12/2018 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 Word No
F-12022A Managed Care Program Provider Appeal Instructions DMS English 02/2020 PDF No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-10112A Medicaid - Disability Application Addendum DMS English 11/2020 PDF No
F-10112AS Medicaid - Disability Application Addendum, Spanish DMS Spanish 11/2020 PDF No
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS English 06/2018 PDF No
F-10151H Medicaid / BadgerCare Plus Fair Hearing Information, Hmong DMS Hmong 06/2018 PDF No
F-10151S Medicaid / BadgerCare Plus Fair Hearing Information, Spanish DMS Spanish 06/2018 PDF No
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update DMS English 02/2014 PDF No
F-10093S Medicaid and BadgerCare Overpayment Notice, Spanish DMS Spanish 09/2019 PDF No
F-10093 Medicaid and BadgerCare Plus Overpayment Notice DMS English 09/2019 PDF No
F-10093S Medicaid and BadgerCare Plus Overpayment Notice, Spanish DMS Spanish 09/2019 Word No
F-10191 Medicaid Annuity Beneficiary Designation DMS English 01/2009 PDF No
F-10192 Medicaid Annuity Information - Disclosure DMS English 01/2009 PDF No
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse DMS English 07/2015 PDF No
F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse, Spanish DMS Spanish 07/2008 PDF No
F-10137 Medicaid Change Report DMS English 06/2023 PDF No
F-10137DA Medicaid Change Report, Dari DMS Dari 06/2023 PDF No
F-10137H Medicaid Change Report, Hmong DMS Hmong 06/2023 PDF No
F-10137PA Medicaid Change Report, Pashto DMS Pashto 06/2023 PDF No
F-10137S Medicaid Change Report, Spanish DMS Spanish 06/2023 PDF No
F-01298 Medicaid Deductible Worksheet DMS English 07/2014 PDF No
Last revised January 24, 2023