Customer Help - Medicaid

To see if you may be able to enroll or to apply, go to


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

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

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.


ForwardHealth Enrollment and Benefits Handbook P-00079 (English, Hmong, Spanish) (PDF 2.6 MB) (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

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: March 19, 2015