Customer Help - Medicaid

To see if you may be able to enroll or to apply, go to ACCESS.wi.gov.

Forms

Application F-10101 (English, Hmong, Spanish) (PDF 268 KB)
To apply apply for Medicaid or you can apply online at ACCESS.wi.gov.

Authorization of Representative F-10126 (English, Hmong, Spanish) (PDF 453 KB)
Designate someone to apply for Medicaid for you.

Change Report F-10137 (English, Hmong, Spanish) (PDF 544 KB)
Report changes to the local agency or you can report changes online at ACCESS.wi.gov.

Disability Application F-10112 (English, Spanish) (PDF 234 KB)
Use this application along with the F-10101 if you need a disability determination.

Fair Hearing Request
To request a hearing if you don't agree with a decision about your benefits.

Fair Hearing Voluntary Withdrawal DHA 17 (PDF 10 KB)
If you want to withdraw your request for a hearing.

Self-Employment Income Report Form (SEIRF) F-00107 (English, Hmong, Spanish) (PDF 90 KB)
Use this form to report self-employment income.

Statement of Identity F-10154  (English, Hmong, Russian, Spanish) (PDF 91 KB)
To provide proof of identity for children under 18 years of age.

Publications

ForwardHealth Enrollment and Benefits Handbook P-00079 (English, Spanish) (PDF 2.6 MB)
A handbook will be mailed to each family who applies for a ForwardHealth Plan.

Guide to Applying for Wisconsin's Health and Nutrition Programs P-16091 (English, Hmong, Spanish) (PDF 181 KB)

ACCESS/Marketplace Takeaway Card P-00555 (English, Spanish) (PDF 549 KB)

Additional Links  

Additional Information about Medicaid can be found at dhs.wisconsin.gov/medicaid

Agency Directory - To find the telephone number and address of your local agency.

Contact a Disability Benefit Specialist or Benefit Specialist at your local Aging and Disability Resource Center (ADRC) or County Aging Office or call 1-800-362-3002.

Find a provider — If you need to find a Medicaid provider in your area.

Income Limits - To find current income limits.

Legal Services — To find the name and telephone number of who in your area can provide you with legal help.  You may also go to:  

Disability Rights of Wisconsin — Disability Rights Wisconsin is a private non profit organization which helps people across Wisconsin gain access to services and opportunity through its advocacy and legal expertise.

Last Revised: January 6, 2015