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Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: July 14, 2008

This list contains BadgerCare forms that are available from DHCAA sorted by the language in which they are written. 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.

Language  Form Title Form Number Form Type Revised Date
English Administrative Disqualification Hearing Notice F-16038 PDF - Fillable 1/1/2008
English BadgerCare Plus / Medicaid Health Insurance Information F-10115 PDF - Fillable 2/1/2008
English BadgerCare Plus Application Packet F-10182 PDF - Fillable 3/1/2008
English BadgerCare Plus Change Report F-10183 PDF - Fillable 1/1/2008
English BadgerCare Plus Premium Employer Wage Withholding F-13025 PDF - Fillable 2/1/2008
English BadgerCare Plus Premium Information F-10139 PDF - Fillable 4/1/2008
English BadgerCare Plus Premium Member / Employer Electronic Funds Transfer F-13026 PDF - Fillable 2/1/2008
English BadgerCare Plus Supplement to FoodShare Wisconsin Application F-10138 PDF - Fillable 1/1/2008
English Designation of a BadgerCare Plus Essential Person F-10186 PDF - Fillable 3/1/2008
English Employer Verification of Health Insurance F-10155 Word - Fillable 4/1/2008
English Employment Verification of Earnings F-10146 Word - Fillable 12/1/2007
English Good Faith Medicaid / BadgerCare Plus Certification F-10111 PDF - Fillable 2/1/2008
English Good Faith Medicaid Certification Instructions F-10111A PDF - Print 8/1/2003
English Income Maintenance Quality Assurance (IMQA) Web Request F-16083 PDF - Fillable 4/1/2005
English Life Insurance Inquiry F-10144 Word - Fillable 1/1/2005
English Local Agency Customer Feedback F-16104 PDF - Print 8/1/2007
English Medicaid / BadgerCare Certification form F-10110 Paper 1/1/1999
English Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative F-10126 PDF - Fillable 2/1/2008
English Medicaid / BadgerCare Plus and Family Planning Services Registration Application F-10129 PDF - Fillable 2/1/2008
English Medicaid / BadgerCare Plus Overpayment Notice F-10093 PDF - Fillable 2/1/2008
English Negative Notice F-16001 PDF - Fillable 1/1/2008
English Notice of Program Violation F-16014 PDF - Fillable 4/1/2005
English Positive Notice F-16015 PDF - Fillable 1/1/2008
English Self-Employment Income Worksheet - Corporation F-16034 PDF - Fillable 3/1/2008
English Self-Employment Income Worksheet - Partnership F-16036 PDF - Fillable 3/1/2008
English Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business F-16037 PDF - Fillable 3/1/2008
English Self-Employment Income Worksheet - Subchapter S Corporation F-16035 PDF - Fillable 3/1/2008
English Social Security Number Referral F-16022 PDF - Fillable 1/1/2008
English Statement of Citizenship and / or Identity for Special Populations F-10161 PDF - Fillable 2/1/2008
English Statement of Identity for Children Under 18 Years of Age F-10154 PDF - Fillable 2/1/2008
English Statement of Identity for Persons in Institutional Care Facilities F-10175 PDF - Print 2/1/2008
English Verification of Veterans Benefits F-10162 PDF - Fillable 2/1/2008
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice F-10143 PDF - Fillable 2/1/2008
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Request F-10141 PDF - Fillable 3/1/2008
English Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions F-10141A PDF - Print 3/1/2008
English Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin F-10150 PDF - Print 8/1/2007
Hmong BadgerCare Plus Application Packet (Hmong) F-10182H PDF - Fillable 3/1/2008
Hmong BadgerCare Plus Change Report (Hmong) F-10183H PDF - Fillable 1/1/2008
Hmong Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) F-10126H PDF - Fillable 2/1/2008
Hmong Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong F-10129H PDF - Fillable 1/1/2003
Hmong Statement of Identity for Children Under 18 Years of Age (Hmong) F-10154H PDF - Fillable 2/1/2008
Russian Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian F-10129R PDF - Fillable 1/1/2003
Russian Statement of Identity for Children Under 18 Years of Age (Russian) F-10154R PDF - Fillable 2/1/2008
Spanish BadgerCare Plus Application Packet (Spanish) F-10182S PDF - Fillable 3/1/2008
Spanish BadgerCare Plus Change Report (Spanish) F-10183S PDF - Fillable 1/1/2008
Spanish BadgerCare Plus Premium Information (Spanish) F-10139S PDF - Fillable 4/1/2008
Spanish Medicaid / BadgerCare Overpayment Notice - Spanish F-10093S PDF - Fillable 3/1/2005
Spanish Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) F-10126S PDF - Fillable 2/1/2008
Spanish Medicaid Health Insurance Information - Spanish F-10115S PDF - Fillable 12/1/2004
Spanish Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish F-10129S PDF - Fillable 1/1/2003
Spanish Negative Notice - Spanish F-16001S PDF - Fillable 4/1/2006
Spanish Positive Notice - Spanish F-16015S PDF - Fillable 4/1/2006
Spanish Statement of Identity for Children Under 18 Years of Age (Spanish) F-10154S PDF - Fillable 2/1/2008
Spanish Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish F-10150S PDF - Print 5/1/2007