Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing. If a form is not available electronically, you will be provided instructions for requesting a paper copy. When you are searching for a form, just enter the number in the search box below.

Assigned Numbersort descending Title Division Other Location
F-10110 Medicaid/BadgerCare Plus Eligibility Certification DMS
F-10111 Good Faith Medicaid / BadgerCare Plus Certification DMS
F-10112 Medicaid Disability Application DMS
F-10112A Medicaid – Disability Application Addendum DMS
F-10114 Medicaid Disability Redetermination Report DMS
F-10115 BadgerCare Plus / Medicaid Health Insurance Information DMS
F-10119 Temporary Enrollment for Family Planning Only Services DMS
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration DMS
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information DMS
F-10126 Appoint, Change, or Remove an Authorized Representative DMS
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption DMS
F-10129 Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application DMS
F-10130 Medicaid Presumptive Disability DMS
F-10137 Medicaid Change Report DMS
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application DMS
F-10139 BadgerCare Plus Premium Information / Payment DMS
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application DMS
F-10141 Wisconsin Funeral and Cemetery Aids Program Application DMS
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant DMS
F-10144 Wisconsin Life Insurance Inquiry DMS
F-10146 Employer Verification of Earnings DMS
F-10147 Wisconsin Veterans Home at King - Medicaid Review DMS
F-10150 Your Rights and Responsibilities for Health Care (Medicaid, BadgerCare Plus, Family Planning Only) / FoodShare DMS
F-10150A Your Rights and Responsibilities for Health Care DMS
F-10150B Your Rights and Responsibilities for FoodShare DMS
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information DMS
F-10154 Statement of Identity for Children Under 18 Years of Age DMS
F-10161 Statement of Citizenship and/or Identity DMS
F-10162 Verification of Veterans Benefits DMS
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding DMS
F-10175 Statement of Identity for Persons in Institutional Care Facilities DMS
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version DMS
F-10182 BadgerCare Plus Application Packet DMS
F-10183 Information Change Report DMS
F-10184 BadgerCare Plus Former Foster Care Youth (FFCY) DMS
F-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication DMS
F-10188 Undue Hardship Waiver Decision for Facility DMS
F-10189 Undue Hardship Bed Hold Notice DMS
F-10190 Medicaid Issuer of Annuity - Notice of Obligation DMS
F-10191 Medicaid Annuity Beneficiary Designation DMS
F-10192 Medicaid Annuity Information - Disclosure DMS
F-10193 Divestment Penalty and Undue Hardship Notice Plus Waiver Request DMS
F-11008 Prior Authorization / Therapy Attachment (PA/TA) DMS
F-11010 Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format DMS
F-11011 Prior Authorization / Birth to 3 Attachment (PA/B3) DMS
F-11014 Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services DMS
F-11016 Prior Authorization Physician Attachment (PA/PA) DMS
F-11018 Prior Authorization Request Form (PA/RF) DMS
F-11019 Prior Authorization / Physician Otological Report (PA/POR) DMS
F-11020 Prior Authorization Request for Hearing Instrument and Audiological Services (PA/HIAS1) DMS


Last Revised: March 23, 2021