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Eligibility Management (Income Maintenance) Home >> IM Forms

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

Last Revised: July 14, 2008

This list contains all Medicaid 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 Agency Response to the State Quality Assurance (QA) Medicaid Finding F-10172 PDF - Fillable 4/1/2007
English Authorization to Disclose Information to Disability Determination Bureau (DDB) F-14014 PDF - Print 7/1/2008
English BadgerCare Plus / Medicaid Health Insurance Information F-10115 PDF - Fillable 2/1/2008
English Community Spouse Asset Share Notice F-10096 PDF - Fillable 4/1/2008
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 Estate Recovery Program (ERP) Disclosure F-13039 PDF - Fillable 7/1/2005
English Estate Recovery Program (ERP) Disclosure Instructions F-13039A PDF - Print 7/1/2005
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 Information for Medicaid Disability Applicants F-10113 PDF - Print 2/1/2008
English Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant F-10142 PDF - Fillable 10/1/2005
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 - Disability Application F-10112 PDF - Fillable 10/1/2007
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 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse F-10095 PDF - Fillable 1/1/2008
English Medicaid Change Report F-10137 PDF - Fillable 1/1/2008
English Medicaid Disability Redetermination Report F-10114 PDF - Fillable 1/1/2004
English Medicaid Income Allocation Notice F-10097 PDF - Fillable 2/1/2008
English Medicaid Manual Notice for Cost of Care Contribution F-10108 PDF - Fillable 4/1/2008
English Medicaid Manual Notice for Cost of Care Contribution Instructions F-10108A PDF - Print 4/1/2008
English Medicaid Member Asset Allocation Notice F-10098 PDF - Fillable 1/1/2008
English Medicaid Presumptive Disability F-10130 PDF - Fillable 4/1/2008
English Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  F-10127 PDF - Fillable 3/1/2008
English Medicaid Purchase Plan (MAPP) Independence Account Registration F-10121 PDF - Fillable 2/1/2008
English Medicaid Purchase Plan (MAPP) Member / Premium Information F-10122 PDF - Print 3/1/2008
English Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  F-13024 PDF - Fillable 12/1/2001
English Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  F-13023 PDF - Fillable 12/1/2001
English Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice F-10106 PDF - Fillable 1/1/2008
English Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice F-10107 PDF - Fillable 1/1/2008
English Medicaid Remaining Deductible Update F-10109 PDF - Print 11/1/2003
English Negative Notice F-16001 PDF - Fillable 1/1/2008
English Notice of Program Violation F-16014 PDF - Fillable 4/1/2005
English Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility F-10099 PDF - Fillable 2/1/2008
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 Student Aid and Expense Worksheet F-16031 PDF - Fillable 12/1/2001
English Student Financial Report F-16021 PDF - Fillable 4/1/2008
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 Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet F-10101 PDF - Fillable 8/1/2008
English Wisconsin Medicaid Supplement to FoodShare Wisconsin Application F-10140 PDF - Fillable 2/1/2008
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 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) F-10126H PDF - Fillable 2/1/2008
Hmong Medicaid Change Report - Hmong F-10137H 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
Hmong Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Hmong) F-10101H PDF - Fillable 8/1/2007
Russian Medicaid Change Report - Russian F-10137R 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
Russian Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Russian) F-10101R PDF - Fillable 8/1/2007
Spanish Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) (Spanish) F-14014AS PDF - Print 7/1/2008
Spanish Information for Medicaid Disability Applicants (Spanish) F-10113S PDF - Print 2/1/2008
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 Change Report - Spanish F-10137S 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 Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Spanish) F-10101S PDF - Fillable 8/1/2007
Spanish Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (Spanish) F-10140S 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