Medicaid: Forms and Publications

Give these forms to Medicaid members (or potential members) if:

• They’re ready to apply for Medicaid.
  • Paper:
    • BadgerCare Plus/Medicaid Health Insurance Information, F-10115
    • Medicaid Disability Application, F-10112—Use this form if you need a disability determination.
    • Wisconsin Medicaid, BadgerCare Plus, and Family Planning Only Services Registration Application, F-10129—Use this form if you need to start your application process and set your application date.
    • Wisconsin Medicaid for the Elderly, Blind, or Disabled Application Packet, F-10101
  • Online—access.wi.gov
• They want someone to act on their behalf. This can be a person or an organization. Learn more from the Representative Types Quick Reference, P-02176
  • Appoint, Change, or Remove an Authorized Representative: Person, F-10126A
  • Appoint, Change, or Remove an Authorized Representative: Organization, F-10126B
• They have a life change. This could mean moving, getting married, or having a child.
  • Paper—Medicaid Change Report, F-10137
  • Online—access.wi.gov
• They need to allow someone to see information about their eligibility. Use the Release of Confidential Information Authorization for Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, SeniorCare, and Caretaker Supplement, F-02340
• They disagree with a decision made by Medicaid. They can request a formal hearing. Use the Request for Fair Hearing form.
• They live with kids under 18 years old. They must share details with Medicaid. Use the Statement of Identity for Children Under 18 Years of Age, F-10154 form.
• They need to transfer property after a member dies. Use the Transfer by Affidavit form. (PDF)

Guides

View these guides to learn more about Medicaid topics. These are helpful to give to Medicaid members:

• Guide to Applying for Wisconsin’s Health, Nutrition, and Other Programs, P-16091
• Medicaid and BadgerCare Plus Private Duty Nursing Guide, P-01122
• Wisconsin Medicaid Purchase Plan (MAPP) Consumer Guide, P-00181
• Wisconsin Medicaid SSI HMO Program Guide, P-12770

Handbooks

• ForwardHealth Enrollment and Benefits Handbook, P-00079—Each family who applies for a ForwardHealth plan gets a handbook in the mail.
• Wisconsin Estate Recovery Program Handbook, P-13032

Brochures and flyers

• BadgerCare Plus or Medicaid SSI HMO Ombuds, P-12002
• Estate Recovery Transfer by Affidavit, P-13009
• HealthCheck: Supporting Your Child’s Health, Brochure, P-01007
• MyACCESS Mobile App Flyer, P-02309
• Prenatal Care Coordination, P-01046

Wallet cards

• ACCESS/Marketplace Takeaway Card (50/pad, order by pad), P-00555
• MyACCESS Mobile App Wallet Card, P-02308

Fact sheets

• BadgerCare Plus and Medicaid Plan—Medical Support Liability, P-10064
• Health Care for Migrant Workers, P-10053
• Health Care for Wisconsin Immigrants, P-10164
• Key Contacts, P-16108
• Medicaid and BadgerCare Plus Emergency Services, P-10072
• Medicaid—Applying for Medicaid Disability Fact Sheet, P-10048
• Medicaid/BadgerCare Plus Deductible Plans, P-10052
• Medicaid—Enrollment Renewal Fact Sheet, P-10049
• Medicaid—Patient Liability, P-10061
• Medicaid Purchase Plan, P-10071
• Medicare Savings Programs, P-10062
• Non-Emergency Medical Transportation
• Wisconsin Estate Recovery Program Policy Changes Effective August 1, 2014 Fact Sheet, P-00694 (PDF)
• Wisconsin Legal Services Programs, P-10096
• Wisconsin Medicaid and BadgerCare Plus Tuberculosis-Related Only Services, P-10022
• Wisconsin Medicaid Divestment, P-10058
• Wisconsin Medicaid—Home and Community-Based Services Waiver Programs, P-10059
• Wisconsin Medicaid Spousal Impoverishment Protection, P-10063
• Wisconsin Well Woman Medicaid, P-10065

Poster

Download the MyACCESS Mobile App Poster, P-02307.