Medicaid Applications and Forms

Medicaid, BadgerCare Plus and Family Planning Waiver Registration Application F-10129 (English, Hmong, Spanish) (PDF 10 KB) (09/13)
Use this form to start your application process and to set your application date. You can also do this online at

Wisconsin Medicaid for the Elderly, Blind and Disabled Application/Renewal F-10101 (English, Hmong, Spanish) (PDF 782 KB) (02/13)
Use this form to apply. You can also apply online at

Medicaid Disability Application F-10112 (English, Spanish) (PDF 263 KB) (03/12)
Use this form to if you need a disability determination.

Medicaid / FoodShare Wisconsin Authorization of Representative F-10126 (English, Hmong, Spanish) (PDF 64 KB) (02/13)
Designate someone to apply for Medicaid for you.

Medicaid Change Form F-10137 (English, Hmong, Spanish) (PDF 75 KB) (01/14)
To report changes. You can also report changes online at

Medicaid Health Insurance Information F-10115 (English, Spanish) (PDF 249 KB) (01/11)

Request For Fair Hearing DHA-28 (PDF 50 KB) — To request a Fair Hearing.

Fair Hearing Voluntary Withdrawal DHA-17 (PDF 11 KB) — To withdraw your Fair Hearing request.

BadgerCare Plus Application Packet F-10182 (English, Hmong, Spanish) (PDF 725 KB) (01/15)

Wisconsin Circuit Courts Transfer by Affidavit ($50,000 and under) PR-1831 — Apply Online

Last Revised: January 14, 2015