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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
BadgerCare Forms Sorted by Form Type

Last Revised: July 14, 2008

This list contains BadgerCare forms that are available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). Forms marked as "PDF-Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Type Form Title Form Number Revised Date Language Text
Paper Medicaid / BadgerCare Certification form F-10110 1/1/1999 English
Paper Temporary Enrollment for BadgerCare Plus Family Planning Waiver F-10119 7/1/2008 English
PDF - Fillable Administrative Disqualification Hearing Notice F-16038 1/1/2008 English
PDF - Fillable BadgerCare Plus / Medicaid Health Insurance Information F-10115 7/1/2008 English
PDF - Fillable BadgerCare Plus / Medicaid Health Insurance Information (Spanish) F-10115S 7/1/2008 Spanish
PDF - Fillable BadgerCare Plus Application / Review Packet F-10182 10/1/2008 English
PDF - Fillable BadgerCare Plus Application Packet (Hmong) F-10182H 3/1/2008 Hmong
PDF - Fillable BadgerCare Plus Application Packet (Spanish) F-10182S 3/1/2008 Spanish
PDF - Fillable BadgerCare Plus Change Report F-10183 1/1/2008 English
PDF - Fillable BadgerCare Plus Change Report (Hmong) F-10183H 1/1/2008 Hmong
PDF - Fillable BadgerCare Plus Change Report (Spanish) F-10183S 1/1/2008 Spanish
PDF - Fillable BadgerCare Plus Premium Employer Wage Withholding F-13025 2/1/2008 English
PDF - Fillable BadgerCare Plus Premium Information F-10139 7/1/2008 English
PDF - Fillable BadgerCare Plus Premium Information (Spanish) F-10139S 7/1/2008 Spanish
PDF - Fillable BadgerCare Plus Premium Member / Employer Electronic Funds Transfer F-13026 2/1/2008 English
PDF - Fillable BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 7/1/2008 English
PDF - Fillable Designation of a BadgerCare Plus Essential Person F-10186 3/1/2008 English
PDF - Fillable Good Faith Medicaid / BadgerCare Plus Certification F-10111 7/1/2008 English
PDF - Fillable Income Maintenance Quality Assurance (IMQA) Web Request F-16083 4/1/2005 English
PDF - Fillable Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S 3/1/2005 Spanish
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 7/1/2008 English
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) F-10126H 7/1/2008 Hmong
PDF - Fillable Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) F-10126S 7/1/2008 Spanish
PDF - Fillable Medicaid / BadgerCare Plus and Family Planning Services Registration Application F-10129 7/1/2008 English
PDF - Fillable Medicaid / BadgerCare Plus Overpayment Notice F-10093 7/1/2008 English
PDF - Fillable Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong F-10129H 1/1/2003 Hmong
PDF - Fillable Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian F-10129R 1/1/2003 Russian
PDF - Fillable Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish F-10129S 1/1/2003 Spanish
PDF - Fillable Negative Notice F-16001 1/1/2008 English
PDF - Fillable Negative Notice - Spanish F-16001S 4/1/2006 Spanish
PDF - Fillable Notice of Program Violation F-16014 4/1/2005 English
PDF - Fillable Positive Notice F-16015 1/1/2008 English
PDF - Fillable Positive Notice - Spanish F-16015S 4/1/2006 Spanish
PDF - Fillable Self-Employment Income Worksheet - Corporation F-16034 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Partnership F-16036 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 3/1/2008 English
PDF - Fillable Self-Employment Income Worksheet - Subchapter S Corporation F-16035 3/1/2008 English
PDF - Fillable Social Security Number Referral F-16022 1/1/2008 English
PDF - Fillable Statement of Citizenship and / or Identity for Special Populations F-10161 2/1/2008 English
PDF - Fillable Statement of Identity for Children Under 18 Years of Age F-10154 7/1/2008 English
PDF - Fillable Statement of Identity for Children Under 18 Years of Age (Hmong) F-10154H 7/1/2008 Hmong
PDF - Fillable Statement of Identity for Children Under 18 Years of Age (Russian) F-10154R 7/1/2008 Russian
PDF - Fillable Statement of Identity for Children Under 18 Years of Age (Spanish) F-10154S 7/1/2008 Spanish
PDF - Fillable Verification of Veterans Benefits F-10162 2/1/2008 English
PDF - Fillable Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice F-10143 7/1/2008 English
PDF - Fillable Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 7/1/2008 English
PDF - Print Good Faith Medicaid Certification Instructions F-10111A 8/1/2003 English
PDF - Print Local Agency Customer Feedback F-16104 8/1/2007 English
PDF - Print Statement of Identity for Persons in Institutional Care Facilities F-10175 2/1/2008 English
PDF - Print Temporary Enrollment for BadgerCare Plus Family Planning Waiver Instructions F-10119A 7/1/2008 English
PDF - Print Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A 7/1/2008 English
PDF - Print Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin F-10150 8/1/2007 English
PDF - Print Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish F-10150S 5/1/2007 Spanish
Word - Fillable Employer Verification of Health Insurance F-10155 4/1/2008 English
Word - Fillable Employment Verification of Earnings F-10146 12/1/2007 English
Word - Fillable Life Insurance Inquiry F-10144 7/1/2008 English