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 ACCESS.wi.gov.

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 ACCESS.wi.gov.

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 ACCESS.wi.gov.

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

ACCESS.wi.gov — Apply Online

Last Revised: January 14, 2015