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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Financing (DHCF)
BadgerCare Forms Sorted by Form Number

Last Revised: July 14, 2008

This list contains BadgerCare forms that are available from DHCF. 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  Number Form Title Form Type Revised Date Language
F-10093 Medicaid / BadgerCare Plus Overpayment Notice PDF - Fillable 7/1/2008 English
F-10093S Medicaid / BadgerCare Overpayment Notice - Spanish PDF - Fillable 3/1/2005 Spanish
F-10110 Medicaid / BadgerCare Certification form Paper 1/1/1999 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification PDF - Fillable 2/1/2008 English
F-10111A Good Faith Medicaid Certification Instructions PDF - Print 8/1/2003 English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information PDF - Fillable 2/1/2008 English
F-10115S BadgerCare Plus / Medicaid Health Insurance Information (Spanish) PDF - Fillable 12/1/2004 Spanish
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative PDF - Fillable 2/1/2008 English
F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) PDF - Fillable 2/1/2008 Hmong
F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) PDF - Fillable 2/1/2008 Spanish
F-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application PDF - Fillable 2/1/2008 English
F-10129H Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong PDF - Fillable 1/1/2003 Hmong
F-10129R Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian PDF - Fillable 1/1/2003 Russian
F-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish PDF - Fillable 1/1/2003 Spanish
F-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application PDF - Fillable 1/1/2008 English
F-10139 BadgerCare Plus Premium Information PDF - Fillable 4/1/2008 English
F-10139S BadgerCare Plus Premium Information (Spanish) PDF - Fillable 4/1/2008 Spanish
F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request PDF - Fillable 3/1/2008 English
F-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF - Print 3/1/2008 English
F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice PDF - Fillable 2/1/2008 English
F-10144 Life Insurance Inquiry Word - Fillable 1/1/2005 English
F-10146 Employment Verification of Earnings Word - Fillable 12/1/2007 English
F-10150 Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin PDF - Print 8/1/2007 English
F-10150S Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish PDF - Print 5/1/2007 Spanish
F-10154 Statement of Identity for Children Under 18 Years of Age PDF - Fillable 2/1/2008 English
F-10154H Statement of Identity for Children Under 18 Years of Age (Hmong) PDF - Fillable 2/1/2008 Hmong
F-10154R Statement of Identity for Children Under 18 Years of Age (Russian) PDF - Fillable 2/1/2008 Russian
F-10154S Statement of Identity for Children Under 18 Years of Age (Spanish) PDF - Fillable 2/1/2008 Spanish
F-10155 Employer Verification of Health Insurance Word - Fillable 4/1/2008 English
F-10161 Statement of Citizenship and / or Identity for Special Populations PDF - Fillable 2/1/2008 English
F-10162 Verification of Veterans Benefits PDF - Fillable 2/1/2008 English
F-10175 Statement of Identity for Persons in Institutional Care Facilities PDF - Print 2/1/2008 English
F-10182 BadgerCare Plus Application Packet PDF - Fillable 3/1/2008 English
F-10182H BadgerCare Plus Application Packet (Hmong) PDF - Fillable 3/1/2008 Hmong
F-10182S BadgerCare Plus Application Packet (Spanish) PDF - Fillable 3/1/2008 Spanish
F-10183 BadgerCare Plus Change Report PDF - Fillable 1/1/2008 English
F-10183H BadgerCare Plus Change Report (Hmong) PDF - Fillable 1/1/2008 Hmong
F-10183S BadgerCare Plus Change Report (Spanish) PDF - Fillable 1/1/2008 Spanish
F-10186 Designation of a BadgerCare Plus Essential Person PDF - Fillable 3/1/2008 English
F-13025 BadgerCare Plus Premium Employer Wage Withholding PDF - Fillable 2/1/2008 English
F-13026 BadgerCare Plus Premium Member / Employer Electronic Funds Transfer PDF - Fillable 2/1/2008 English
F-16001 Negative Notice PDF - Fillable 1/1/2008 English
F-16001S Negative Notice - Spanish PDF - Fillable 4/1/2006 Spanish
F-16014 Notice of Program Violation PDF - Fillable 4/1/2005 English
F-16015 Positive Notice PDF - Fillable 1/1/2008 English
F-16015S Positive Notice - Spanish PDF - Fillable 4/1/2006 Spanish
F-16022 Social Security Number Referral PDF - Fillable 1/1/2008 English
F-16034 Self-Employment Income Worksheet - Corporation PDF - Fillable 3/1/2008 English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation PDF - Fillable 3/1/2008 English
F-16036 Self-Employment Income Worksheet - Partnership PDF - Fillable 3/1/2008 English
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business PDF - Fillable 3/1/2008 English
F-16038 Administrative Disqualification Hearing Notice PDF - Fillable 1/1/2008 English
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request PDF - Fillable 4/1/2005 English
F-16104 Local Agency Customer Feedback PDF - Print 8/1/2007 English